US Territories Child Medical Consent

This document is accurate and up to date! It was last reviewed by a lawyer in November 2024.

US Territories Child Medical Consent

A Child Medical Consent is used to give a third party the power to authorize the provision of emergency care, medical and dental procedures, and/or other health care treatments to your child. It also contains information related to your child's medical history (such as allergies and medications) and the contact information of his/her family health care providers.


Simply answer the questions below to personalize your Child Medical Consent

Child Medical Consent template free sample

Sample Child Medical Consent

US Territories Child Medical Consent


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Governing Jurisdiction:

Parent/Guardian Information:

A child's legal guardian is the person they live with, and who takes care of them. In most cases, this is the parents, or a single parent if there is not joint custody.

If both parents live together, select ONE legal guardian and type both parent's names in the name box.
 

First Guardian's Information:

First Guardian's Residence:

Select "At home or at work" if you will be around your area of residence.

Contact Information:

Contact Information:

 

Second Guardian's Information:

Second Guardian's Residence:

Select "At home or at work" if you will be around your area of residence.

Contact Information:

Contact Information:

 

Number of Children:

 

First Child's Information:

Personal Information:

Place of Residence:

If the child lives with both guardians (who have the same address), you can select either guardian.

Where does the child reside?

Medical Information:

 

Second Child's Information:

Personal Information:

Place of Residence:

If the child lives with both guardians (who have the same address), you can select either guardian.

Where does the child reside?

Medical Information:

 

Third Child's Information:

Personal Information:

Place of Residence:

If the child lives with both guardians (who have the same address), you can select either guardian.

Where does the child reside?

Medical Information:

 

Fourth Child's Information:

Personal Information:

Place of Residence:

If the child lives with both guardians (who have the same address), you can select either guardian.

Where does the child reside?

Medical Information:

 

Fifth Child's Information:

Personal Information:

Place of Residence:

If the child lives with both guardians (who have the same address), you can select either guardian.

Where does the child reside?

Medical Information:

 

Sixth Child's Information:

Personal Information:

Place of Residence:

If the child lives with both guardians (who have the same address), you can select either guardian.

Where does the child reside?

Medical Information:

 

Health Care Providers:

 

Escort Information:

Specify anything do NOT want your escort(s) to consent to, E.g. Blood transfusion, X-rays, etc.

 

Length of Consent:

 

Signing Conditions:

Date of Signing:

Witnesses:

We highly recommend the presence of a notary public and two witnesses at the signing of this document, to ensure its validity.