USA 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

Governing Jurisdiction:

This document will be governed by the laws of which nation?

Select a State:

Select a Province or Territory:

Select a State / Territory:

Select a Country:

Select a Region:

Select a State or Union Territory:

Select a State or District:

Select a State:

Select a Region:

Select a Province:

Select a Province or Region:

Select a State or Region:

Select a Division:

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.

How many legal guardians does the child(ren) have?

First Guardian's Information:

First Guardian's Name:

First Guardian's Residence:

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

During this consent, I can be reached:

Name (e.g. Hotel name, friend's name, etc):

Address:

City:

State/Province:

Postal/Zip Code:

Contact Information:

Home Phone (e.g. (302) 472-7392):

Work Phone:

Mobile Phone:

Fax:

E-mail:

Second Guardian's Information:

Second Guardian's Name:

Second Guardian's Residence:

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

During this consent, I can be reached:

Name (e.g. Hotel name, friend's name, etc):

Address:

City:

State/Province:

Postal/Zip Code:

Contact Information:

Home Phone (e.g. (302) 472-7392):

Work Phone:

Mobile Phone:

Fax:

E-mail:

Number of Children:

How many children do you wish to give a consent for?

First Child's Information:

Personal Information:

Full Name (e.g. George Robert Smith):

Gender:

Age:

Date of Birth (e.g. June 12th, 1999):

Place of Birth (e.g. Toronto, Canada):

Place of Residence:

Does this child live with the above guardian(s)?

Yes

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

Which guardian?

Where does the child reside?

Address:

City:

State/Province:

Postal/Zip Code:

Medical Information:

Do you wish to include your child's blood type?

Yes

Select the blood type:

Do you wish to include your child's Rh Factor?

Yes

Select the Rh type:

Is your child on any medication?

Yes

Provide a detailed description of the medication(s):

Does your child have other illnesses or conditions?

Yes

Provide a detailed description of the condition(s):

Do you wish to provide health insurance details for this child?

Yes

Describe the health insurance:

Second Child's Information:

Personal Information:

Full Name:

Gender:

Age:

Date of Birth (e.g. March 2nd, 1999):

Place of Birth:

Place of Residence:

Does this child live with the above guardian(s)?

Yes

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

Which guardian?

Where does the child reside?

Address:

City:

State/Province:

Postal/Zip Code:

Medical Information:

Do you wish to include your child's blood type?

Yes

Select the blood type:

Do you wish to include your child's Rh Factor?

Yes

Select the Rh type:

Is your child on any medication?

Yes

Provide a detailed description of the medication(s):

Does your child have other illnesses or conditions?

Yes

Provide a detailed description of the condition(s):

Do you wish to provide health insurance details for this child?

Yes

Describe the health insurance:

Third Child's Information:

Personal Information:

Full Name:

Gender:

Age:

Date of Birth (e.g. March 2nd, 1999):

Place of Birth:

Place of Residence:

Does this child live with the above guardian(s)?

Yes

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

Which guardian?

Where does the child reside?

Address:

City:

State/Province:

Postal/Zip Code:

Medical Information:

Do you wish to include your child's blood type?

Yes

Select the blood type:

Do you wish to include your child's Rh Factor?

Yes

Select the Rh type:

Is your child on any medication?

Yes

Provide a detailed description of the medication(s):

Does your child have other illnesses or conditions?

Yes

Provide a detailed description of the condition(s):

Do you wish to provide health insurance details for this child?

Yes

Describe the health insurance:

Fourth Child's Information:

Personal Information:

Full Name:

Gender:

Age:

Date of Birth (e.g. March 2nd, 1999):

Place of Birth:

Place of Residence:

Does this child live with the above guardian(s)?

Yes

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

Which guardian?

Where does the child reside?

Address:

City:

State/Province:

Postal/Zip Code:

Medical Information:

Do you wish to include your child's blood type?

Yes

Select the blood type:

Do you wish to include your child's Rh Factor?

Yes

Select the Rh type:

Is your child on any medication?

Yes

Provide a detailed description of the medication(s):

Does your child have other illnesses or conditions?

Yes

Provide a detailed description of the condition(s):

Do you wish to provide health insurance details for this child?

Yes

Describe the health insurance:

Fifth Child's Information:

Personal Information:

Full Name:

Gender:

Age:

Date of Birth (e.g. March 2nd, 1999):

Place of Birth:

Place of Residence:

Does this child live with the above guardian(s)?

Yes

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

Which guardian?

Where does the child reside?

Address:

City:

State/Province:

Postal/Zip Code:

Medical Information:

Do you wish to include your child's blood type?

Yes

Select the blood type:

Do you wish to include your child's Rh Factor?

Yes

Select the Rh type:

Is your child on any medication?

Yes

Provide a detailed description of the medication(s):

Does your child have other illnesses or conditions?

Yes

Provide a detailed description of the condition(s):

Do you wish to provide health insurance details for this child?

Yes

Describe the health insurance:

Sixth Child's Information:

Personal Information:

Full Name:

Gender:

Age:

Date of Birth (e.g. March 2nd, 1999):

Place of Birth:

Place of Residence:

Does this child live with the above guardian(s)?

Yes

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

Which guardian?

Where does the child reside?

Address:

City:

State/Province:

Postal/Zip Code:

Medical Information:

Do you wish to include your child's blood type?

Yes

Select the blood type:

Do you wish to include your child's Rh Factor?

Yes

Select the Rh type:

Is your child on any medication?

Yes

Provide a detailed description of the medication(s):

Does your child have other illnesses or conditions?

Yes

Provide a detailed description of the condition(s):

Do you wish to provide health insurance details for this child?

Yes

Describe the health insurance:

Health Care Providers:

Do you wish to list your family doctor's contact information?

Yes

Name:

Address:

City:

Country:

Zip:

Phone (e.g. (294) 395-4839):

Emergency Phone (e.g. (305) 396-6945):

Do you wish to list your family dentist's contact information?

Yes

Name:

Address:

City:

Country:

Zip:

Phone (e.g. (294) 395-4839):

Emergency Phone (e.g. (305) 396-6945):

Escort Information:

How many escorts will have authority over your child(ren)'s health care?

First Escort:

Second Escort:

Address:

City:

State/Province:

Zip Code:

Do you wish to limit the authority of the escort(s)?

Yes

How many limits do you wish to impose?

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

First Item:

Second Item:

Third Item:

Fourth Item:

Fifth Item:

Do you wish to limit the location(s) that this document is effective in?

Yes

Which locations will this document be VALID in?

Length of Consent:

This consent will become effective (e.g. January 17th, 2024):

This consent will END on (e.g. December 28th, 2024):

Signing Conditions:

Date of Signing:

Day (e.g. 2):

Month (e.g. January):

Year (e.g. 2024):

Witnesses:

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

Will this document be signed in front of two witnesses?

Yes

Will a notary public be present?

Yes

Country of Signing:

Province:

State:

Select a Country:

Select a State / Territory:

Select a State or Union Territory:

Select a Region:

Select a State or District:

Select a State:

Select a Region:

Select a Province:

Select a Province or Region:

Select a State or Region:

Select a Division:

Country:

Free USA Child Medical Consent Templates

The sample documents below are provided for informational purposes only.

They are NOT up to date;
They have NOT been reviewed by a Lawyer;
They may NOT be legally valid or enforceable.

We strongly recommend obtaining an attorney reviewed Child Medical Consent directly from us.

Below are some random samples we have created with Documatica. Please note that these documents reflect a certain set of answers, and it is very likely that the document you require is different. Do not rely on the templates below - create your own customized Child Medical Consent with our webpage.

Child Medical Consent (USA) Sample 27MvmF1.pdf

For maximum legal protection, obtain a lawyer reviewed Child Medical Consent directly from us.

USA Child Medical Consent

USA Child Medical Consent

This legal document is also known as:

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Related External Links

Governing Jurisdiction:

Parent/Guardian Information:

First Guardian's Information:

First Guardian's Residence:

Contact Information:

Contact Information:

Second Guardian's Information:

Second Guardian's Residence:

Contact Information:

Contact Information:

Number of Children:

First Child's Information:

Personal Information:

Place of Residence:

Where does the child reside?

Medical Information:

Second Child's Information:

Personal Information:

Place of Residence:

Where does the child reside?

Medical Information:

Third Child's Information:

Personal Information:

Place of Residence:

Where does the child reside?

Medical Information:

Fourth Child's Information:

Personal Information:

Place of Residence:

Where does the child reside?

Medical Information:

Fifth Child's Information:

Personal Information:

Place of Residence:

Where does the child reside?

Medical Information:

Sixth Child's Information:

Personal Information:

Place of Residence:

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:

Free USA Child Medical Consent Templates