Child Medical Consent and Authorization for Treatment
I, [Parent: full name], of [Parent: address], telephone [Parent: phone], am the [Your relationship to the child] of [Child: full name], born [Child: date of birth] (the “Child”), and have legal authority to consent to the Child’s medical care. By this Child Medical Consent (the “Consent”) I authorise [Caregiver: full name], the Child’s [Caregiver: relationship to child], of [Caregiver: address], telephone [Caregiver: phone] (the “Caregiver”), to consent to medical care for the Child on my behalf during the period and within the limits set out below.
1. Period of Consent
This Consent is effective from [Consent begins] to [Consent ends], inclusive, and during any short extension of the Caregiver’s care of the Child caused by travel delay or my unavailability, until I resume care of the Child or revoke this Consent. It applies whenever the Child is in the Caregiver’s care during that period, whether at the Caregiver’s home, my home or elsewhere.
2. Consent to Treatment
I authorise the Caregiver, when I cannot be reached promptly, to consent on my behalf to the following care for the Child by a licensed physician, dentist, nurse practitioner, hospital, urgent care clinic or emergency medical service: [Treatment the caregiver may consent to]. This includes examination, diagnostic tests, x-rays, immunisations where due, prescription and administration of medication, treatment of illness and injury, and, within the scope chosen, anaesthesia, surgery and admission to hospital. I authorise any such provider to treat the Child on the Caregiver’s consent as fully as if I had given it in person.
3. Limits
The Caregiver’s authority is subject to these restrictions, and the following treatments require my own consent in every case: [Restrictions or treatments needing your own consent (or “None”)]. The Caregiver may not consent to any treatment that I could not consent to myself, to the withholding or withdrawal of life-sustaining treatment, to sterilisation, to participation in research, or to any treatment I have expressly refused, and shall in every case contact me before non-emergency treatment where the scope in Section 2 requires it.
4. Health Information
The Child’s allergies are: [Allergies (or “None known”)]. Current medications: [Current medications and doses (or “None”)]. Medical conditions and relevant history: [Medical conditions and history (or “None”)]. The Child’s physician is [Child’s physician: name and practice], telephone [Physician: phone], and I ask that the physician be consulted where practical. In an emergency, my preferred hospital is: [Preferred hospital (or “Nearest”)], but the Caregiver may use whichever facility is nearest or most appropriate.
5. Release of Information
I authorise every provider treating the Child during the period of this Consent to disclose the Child’s health information, including diagnosis, treatment and records, to the Caregiver, and to discuss the Child’s condition with the Caregiver, so that the Caregiver can carry out this Consent and keep me informed. I authorise the Child’s physician to disclose the Child’s history to any treating provider. For this purpose I intend the Caregiver to be treated as a person involved in the Child’s care under 45 CFR §164.510(b).
6. Insurance and Payment
The Child is covered by [Health insurance: carrier and plan], policy or member number [Policy or member number], policy holder [Policy holder: name]. The Caregiver may present this information and sign the provider’s consent and financial responsibility forms as my agent. I am responsible for the cost of the Child’s care, including any amount not covered by insurance, and I will reimburse the Caregiver within fourteen days for any amount the Caregiver pays for the Child’s care, on presentation of receipts.
7. Duty to Contact Me
The Caregiver shall try to reach me at the telephone number and email in this Consent before consenting to any treatment other than emergency care, and shall inform me as soon as possible of any illness, injury, emergency visit, admission or prescription, whether or not I was reached beforehand. If I cannot be reached, the Caregiver may contact [Alternative contact if you cannot be reached], who may relay my instructions but may not consent in my place unless they hold their own authority. Once I am reached, my instructions control.
8. Nature of This Consent
This Consent does not transfer custody or guardianship of the Child, does not authorise the Caregiver to make decisions about the Child’s schooling, residence, travel or religion, and does not limit my authority as parent. It does not change any custody order. If more than one person has legal custody of the Child, each has signed this Consent or has separately consented to it.
9. Revocation
I may revoke this Consent at any time by written notice to the Caregiver, effective when received. Revocation does not affect treatment already begun in reliance on this Consent, and a provider who has not received notice of revocation may continue to rely on it. This Consent expires automatically on the end date in Section 1 unless I extend it in writing.
10. Reliance; Release
Any provider, facility, pharmacy or emergency service may rely on this Consent, or on a photocopy, scan or electronically signed copy of it, without further inquiry, and I release any provider who acts in good faith on the Caregiver’s consent under it from liability for having done so, to the same extent as if I had consented myself. I agree to indemnify the Caregiver against any claim arising from a decision made in good faith and within the scope of this Consent.
11. Governing Law; Signatures
This Consent is governed by the laws of the State of [Governing law (state)]. If any provision is held invalid, the remaining provisions shall be given full effect. It may be signed electronically and in counterparts, and the electronic execution record, timestamps and document fingerprints kept by the signing platform are evidence of execution; where a provider or the law of my state requires it, I intend to have my signature acknowledged before a notary public on a printed copy, and that copy shall be an original of this Consent. I sign on the date shown in the execution record and declare that the statements in this Consent are true and that I have authority to give it.
12. Acceptance by Caregiver
I, [Caregiver: full name], accept the authority given in this Consent. I confirm that I have read the Child’s health information in Section 4 and the limits in Section 3, that I will act only within them and in the Child’s best interest, that I will try to contact the parent before any non-emergency treatment and inform the parent of any treatment promptly, and that I will keep this Consent with me whenever the Child is in my care. I sign on the date shown in the execution record.
Signatures
Parent or legal guardian · Caregiver (authorised adult)