Free Child Medical Consent

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Child Medical Consent

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Your Child Medical Consent

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AUTHORISATION TO CONSENT TO MEDICAL TREATMENT OF CHILD

  1. We, ____________________ and ____________________ of ________________________ make oath and say that we are the lawful guardians of the child listed below and there are no court orders now in effect that would prohibit us from conferring the power to consent upon another person.

    Information of Child

    ____________________, male, born 17 July 2018 at ________________________ and residing at ________________________

  2. We hereby authorise and appoint ____________________ of ________________________ as our agent. Our agent may consent to our child's
    1. transportation by ambulance
    2. examination
    3. x-rays
    4. diagnoses
    5. hospitalisation
    6. anaesthesia
    7. medication

    We do not authorise ____________________ to consent to the transfusion of blood.

  3. Our agent may have access to any and all records, including, but not limited to, insurance records regarding any medical services or treatment provided.
  4. The purpose of this instrument is to give ____________________ the power and authority to consent to medical treatment for our child. This power and authority will be effective as of the 17th day of July, 2018.
  5. We give this consent freely and knowingly in order to provide for the child and not as a result of coercion, duress or payments by any person or agency.
  6. This consent will remain in effect until it is revoked by notifying our child's medical, mental health care and insurance providers, in writing, and the agent named above that we wish to revoke it.
  7. Any questions or concerns regarding this authorisation may be directed to us at:

    Name: ____________________
    Address: ________________________
    Phone Number: ____________________
    Secondary Phone: ____________________
    Email: ____________________



NOTARY ACKNOWLEDGEMENT

Declared at (city) _______________________ on the 17th day of July, 2018.

Before me, (Notary's name) _______________________________

Signature ____________________________________ (Seal)
NOTARY PUBLIC IN AND FOR THE COUNTY OF , ENGLAND

Address ___________________________

Telephone __________________________

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