Minor/Child Medical Consent Form Instructions:
To watch a video on how to fill out a Minor Medical Consent Form click on the link below.
Paragraph 1. – Enter the name and address of the parent(s) or legal guardian(s) of the child
Paragraph 2. – Enter the name and address of the person whom you are authorizing to provide, seek and obtain medical care and treatments for your child in your absence.
Paragraph 3. – Enter the period of time that tis authorization is valid for. Enter a start date, as well as an end date. It is highly recommended that you enter an end date and not leave this authorization open ended. Many states require that this consent form have an end date ranging from six months to a year.
Paragraph 4. – Child’s Information:
Subsection i: Enter the Child’s full legal name, gender, date of birth and home address.
Subsection ii: Enter the child’s health insurance information- include the plan name, policy number, group number and any other pertinent information.
Subsection iii: Next, enter any allergies, illnesses and/or medical conditions of the child.
Subsection iv: Enter any medications that the child is currently taking, include frequency and dose amount.
**If you have more than one child, it is best to create a separate Minor Medical Consent and Authorization form for each child.
Paragraph 5. – Enter the name of the temporary caregiver here. In this paragraph you are consenting to which treatments and medical care the temporary caregiver may obtain and consent to.
Paragraph 6. – If there is any treatment or medical care that you do not authorize the temporary caregiver to consent to or to obtain for your child state it in this paragraph. If there is none, write Not Appliable.
Paragraph 7. – Access to Medical Records. Do you want the temporary caregiver to have access to your child’s medical record? Circle the option that you want-either does or does not in this paragraph.
Paragraph 8. – Physician Information: Enter your family doctor’s/pediatrician’s name and contact information, including address, phone numbers, and email, if applicable. You may enter more than one doctor if you feel it necessary.
Paragraph 9. – Parent(s)/Guardian Contact Information: Enter your Contact information here, include your full legal name, any phone numbers, address and email that you can be reached at.
Paragraph 10. – Emergency Contact: Enter a person that will be your emergency contact should the appointed caregiver try to contact you and not be able to reach you.
Signature: Enter the date that you are signing this authorization form, enter it as day, month and year. And the city and state where you are located.
Notarization: It is a good idea to have this document notarized.
Witnesses: if you do not notarize this document, it is a good idea to have your signature witness.
You may discard the notary acknowledgement page or the witness page, whichever you do not use.