Medical Consent for Minor Template

This Medical Consent for Minor (“Consent Form”) is executed on [Date] by:

Parent/Guardian Name: [Full Legal Name]
Address: [Address]
Phone: [Phone Number]
Email: [Email Address]

Minor’s Name: [Full Legal Name]
Date of Birth: [MM/DD/YYYY]
Address: [Address]

1. Authorized Adult

I hereby authorize the following person(s) to seek medical care for my child:
Name: [Authorized Adult’s Name]
Relationship to Minor: [e.g., aunt, teacher, coach]
Phone: [Phone Number]
Email: [Email Address]

2. Scope of Consent

The authorized adult may consent to:

• Emergency medical treatment, including surgery and anesthesia.

• Routine medical care such as check-ups and vaccinations.

• Administration of prescription and over-the-counter medications.

3. Medical Information

Primary Care Physician: [Name, Contact Information]
Health Insurance Provider: [Provider Name]
Policy Number: [Policy Number]
Known Allergies: [List of allergies or “None”]
Existing Medical Conditions: [List or “None”]

4. Duration of Authorization

This consent is valid from [Start Date] to [End Date], unless revoked in writing by the Parent/Guardian.

5. Emergency Contact

If the Parent/Guardian cannot be reached, the following person should also be contacted:
Name: [Emergency Contact Name]
Relationship: [Relationship to Minor]
Phone: [Phone Number]

6. Liability Release

I release and hold harmless the authorized adult and healthcare providers from any liability resulting from medical treatment provided under this consent, except in cases of gross negligence or willful misconduct.

7. Governing Law

This Consent Form shall be governed by the laws of [State/Country].

Signatures

Parent/Guardian Signature: ________________________ Date: _________
Printed Name: ____________________________________

Witness or Notary (if required): ____________________ Date: _________
Printed Name: ____________________________________