Parental Medical Consent Form

June 17, 2011

A parental medical consent form is very important when a medical emergency arises and it is impossible to get in touch with the parents. A parental medical consent form can come in handy as a tool to give instructions to a child caregiver when a child has travelled and so on.  Occasionally, you may need a temporary guardian to make decisions in your absence. Below is a sample parental medical consent form.
Sample Parental Medical Consent Form

Name of parties to this agreement:  ____________________

Parent Full Name: __________________________________

Social Security details:  ____________________

Address: _______________________________

Child Full Name: _______________________________

Birth Date: _________________
Guardian Name: __________________________

Social Security details: _______________

Address: _________________________

Telephone: _________________

I  _________________________ (parent name) hereby authorize the guardian to administer general first aid treatment related to minor injuries as experienced by the child with exception on the following first aid treatments

________________________

I authorize the guardian to make decisions relating to different medical procedures like blood transfusion, surgery and other forms of necessary treatment in my absence.
Persons involved should note the following allergies

_________________________

Medical insurance details:

I _______________ declare that I am the legal custodian of the child and take full responsibility of all costs.

Name of parent: __________________________________

Signature: __________________

Date:  ______________________________

Witnesses: ________________________

Signature: __________________________

Date: ______________________________

 

Download Parental Medical Consent Form in Word Format

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