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): ___________________