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Medical Consent Form for Minor Template
Authorize medical treatment for a child with clear parent consent and caregiver authority using this Medical Consent Form for Minor Template.
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Medical Consent Form for Minor Template
Date: [Date]
Effective Date: [Effective Date]
Expiration Date (Optional): [Expiration Date]
1. Parent/Legal Guardian Information
1.1 Parent/Guardian Full Name: [Name]
1.2 Relationship to Child: ☐ Mother ☐ Father ☐ Legal guardian ☐ Other: [Relationship]
1.3 Address: [Address]
1.4 Phone: [Phone]
1.5 Email (Optional): [Email]
2. Minor (Child) Information
2.1 Child Full Legal Name: [Name]
2.2 Date of Birth: [MM/DD/YYYY]
2.3 Address (if different): [Address]
2.4 School/Camp/Program (Optional): [Name]
3. Authorized Adult / Caregiver
3.1 Full Name: [Name]
3.2 Relationship to Child: [Relationship]
3.3 Phone/Email: [Contact]
3.4 Address: [Address]
4. Medical Authorization
4.1 I, [Parent/Guardian Name], authorize the caregiver named above to consent to medical evaluation and treatment for the child, including:
☐ Routine medical care
☐ Dental care
☐ Vision care
☐ Urgent care visits
☐ Emergency medical treatment and hospital admission (if needed)
4.2 Provider/Facility Preference (Optional): [Preferred doctor/hospital].
4.3 Treatment Limitations (Optional): [Limits, exclusions, religious restrictions, etc.].
4.4 Notification. Caregiver must attempt to contact me as soon as possible at the phone/email listed above.
5. Medical and Insurance Information (Optional)
5.1 Primary Physician/Pediatrician: [Name/Phone]
5.2 Insurance Provider: [Provider]
5.3 Policy/Member ID: [ID]
5.4 Group Number (Optional): [Group]
5.5 Allergies: [List]
5.6 Current Medications: [List]
5.7 Medical Conditions (Optional): [List]
5.8 Immunizations Up to Date: ☐ Yes ☐ No ☐ Unknown
6. Emergency Contacts (Optional)
6.1 Emergency Contact #1: [Name, relationship, phone]
6.2 Emergency Contact #2: [Name, relationship, phone]
7. Term and Revocation
7.1 This authorization begins on the Effective Date and ends on the Expiration Date (if any), unless revoked earlier in writing.
7.2 I may revoke this authorization at any time by providing written notice to the caregiver and, if applicable, the provider or program.
8. Reliance by Providers
8.1 Medical providers may rely on this consent to the extent permitted by law.
Signatures
Parent/Legal Guardian: [Full Name]
Date: [Date]
Signature: ___________________________
Authorized Adult/Caregiver (Acknowledgment, Optional): [Full Name]
Date: [Date]
Signature: ___________________________
Witnesses (If Required)
Witness #1 Name: [Name]
Date: [Date]
Signature: ___________________________
Witness #2 Name: [Name]
Date: [Date]
Signature: ___________________________
Notary / Notarization (Optional)
State of [State]
County of [County]
On [Date], before me, [Notary Name], personally appeared [Parent/Legal Guardian Name], known to me (or satisfactorily proven) to be the person whose name is subscribed to this document, and acknowledged that they executed it for the purposes stated.
Notary Public Signature: _______________________
My Commission Expires: _______________________
Notary Seal (if applicable): ___________________
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Medical Consent Form for Minor Template
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For quick answers, scroll below to see the FAQ.
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
MEDICAL CONSENT FORM FOR MINOR TEMPLATE FAQ
What is a medical consent form for a minor?
A Medical Consent Form for Minor is a document where a parent or legal guardian authorizes another adult (or a specific provider) to consent to medical treatment for a child when the parent cannot be present. It helps schools, caregivers, and medical providers treat a minor promptly in routine or emergency situations.
When should you use a minor medical consent form?
Use it for travel, school activities, babysitters, sports teams, camps, or temporary caregiving situations — especially when the parent may be unreachable. It’s also useful if the child routinely stays with relatives or another caregiver.
What does the form typically cover?
It usually includes: the child’s information, authorized caregiver details, consent for routine and emergency care, treatment limitations (if any), insurance information, allergies/medications, and emergency contacts. This template also includes a revocation section and an optional notarization section.
Does it need to be notarized?
Not always, but notarization can increase acceptance by hospitals and providers. Some organizations require notarization. This template includes an optional notary section.
Can you limit the consent?
Yes. You can limit types of treatment, specific providers, travel dates, or add special instructions. This template includes a clear section for limits and restrictions.
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