Create your Free Child Medical Consent

Information of parent/guardian

Frequently Asked Questions

Who is a guardian?A guardian is an individual who has to right to make decision on behind of the child. The guardian is generally appointed by local law or court order, or upon the death of a parent through the parent's will to have custody of the child.Do I need both parents signing?Unless there was no father, or one of the parent has died, or you have an order granting full custody, you should have both parents signing the document.

Emergency Contact Info

Frequently Asked Questions

What if I am working away from the primary home?If the parent/guardian is working in another city or in a foreign country which has a different address and phone number than the primary home, the alternate contact information would serve better as the emergency contact. Just select "Use alternate address", and fill it out accordingly.

Otherwise select "Use address provided" as the default emergency contact.

Child Information


Information of Child

(e.g. Dallas, Texas)
The child's address should be the same as the parents' address.

If there is only one parent or the parent has sole custody, or both parents reside at the same address, the first Parent/Guardian address is the default address of the child and it does not need to be entered here again.

In the case of joint custody with two parents at different addresses, the child's address should be the same address as the parent that the child stays with the majority of the time.

Temporary Caregiver(s)

Information of Temporary Caregiver

Frequently Asked Questions

Who is a temporary caregiver?The temporary caregiver can make medical decisions on their behalf for the child when the parents are not available.

Effective Dates

Frequently Asked Questions

What is the start date?The start date is the date which the consent becomes effective and the temporary caregiver can begin to make medical decisions on behalf of the child.What is the end date?The end is the date which the consent expires and the temporary caregiver will not have the power to make medical decisions on behalf of the child.

If no end date is selected, the power of the temporary caregiver will continue indefinitely until the parent/guardian revokes it with a written notice to the proper parties.
How do I end the authority of the temporary caregiver if I don't specify an end date?The parent/guardian may end the consent at any time by notifying the child's medical, mental health care and insurance providers in writing, which ever is applicable, that they wish to revoke the consent granted to the temporary caregiver.

Powers of Temporary Caregiver

Can consent to the following health care examinations and treatments:
Frequently Asked Questions

What is a blood transfusion?Blood transfusion is a procedure where the person receives blood through intravenuous line inserted into the blood vessels.

Family Physician

Signing Details



Frequently Asked Questions

What is the signing date?The signing date is the date where the parents sign the consent form in front of witnesses or a notary.

Even if each parent resides in separate cities and signs in front of different witnesses, the document has to be signed on the same date since it's the day the consent form takes effect.
Who should be witness to the signing?The witnesses should be an independent third party who has no ties to the parent or child. The temporary guardian or guardians should not be your witnesses. In most cases, it is ideal to have a notary notarize the document.
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