Free Child Medical Consent Form

Child medical consent allows parents and legal guardians to grant authority over their child’s healthcare decisions to a caregiver. Create your own printable, free child medical consent form now.

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Last Update July 18th, 2024

Also Known As

Minor Medical Consent Form

Medical Treatment Authorization Form

Child Medical Release Form

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CHILD MEDICAL CONSENT FORM
First Child's Information

Child's full name: _________
Date of Birth: _________
Place of Birth: _________
Address: _________
Parent/Legal Guardian Information
I, _________, parent or legal guardian of _________ do hereby swear and declare that I am the parent or the legal guardian of the child/children herein listed and that there are no court orders preventing the parent or guardian from granting this authorization.
In case of an emergency, the parent(s) or legal guardian(s) should be contacted at the following:

Name: _________
Address: _________
Phone Number: _________
Secondary Phone: _________
Email: _________
Caregiver Details and Consent Information
I name and authorize the following as my Caregiver(s):

_________ residing at _________.

The parent(s) or legal guardian(s) authorize the Caregiver(s) to obtain and consent to any Emergency Medical Care and Treatment, including hospitalization, anesthesia, surgery, and blood transfusion.

The parent(s) or legal guardian(s) authorize the Caregiver(s) to obtain and consent to any Routine Medical Care and Treatment, including Dental Care, and Treatment.
I DO NOT authorize the Caregiver(s) to have access to any medical information.
Consent Details

This granting of authority will be effective on _________.
I agree that this is an informed consent, given freely and with certain knowledge of its purpose, in order to provide medical care for the child/children.
The authority granted under this Child Medical Consent form may be terminated through a written notification addressed to the Caregiver(s) named above and to the child/children's medical and insurance providers, stating that I wish to revoke it.
NOTARY ACKNOWLEDGEMENT


I hereunto sign my name at ____________________, Alabama this ________________ day of ____________, ________.

_________________________________
_________


STATE OF ALABAMA

COUNTY OF ____________________

I ____________________________, a Notary Public in and for said County and State, hereby certify that ____________________________, having signed this Child Medical Consent, and being known to me (or whose identity/ies has/have been proven on the basis of satisfactory evidence), acknowledged before me on this day that, being informed of the contents of the conveyance, the ____________________________ has executed this Child Medical Consent voluntarily and with lawful authority.

Given under my hand this ________________ day of ____________, ________.


_______________________________
Notary Public for the State of Alabama

My commission expires: __________________________
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