1. Identification of Parties and Child
Child's Information:
- Full legal name: [[Child Full Name]]
- Date of birth: [[Child Date of Birth]]
- Age: [[Child Age]]
- Gender: [[Child Gender]]
- Home address: [[Child Home Address]]
- Primary phone: [[Child/Parent Primary Phone]]
Parent/Guardian Granting Authority:
- Full name: [[Parent/Guardian Full Name(s)]]
- Relationship to Child: [[Parent/Guardian Relationship e.g. Mother, Father, Legal Guardian]]
- Contact phone: [[Parent/Guardian Phone Number]]
- Email: [[Parent/Guardian Email]]
- Alternate emergency contact: [[Alternate Emergency Contact Name and Phone]]
Authorized Caregiver:
- Full name: [[Caregiver Full Name]]
- Relationship to Child: [[Caregiver Relationship e.g. Grandparent, Babysitter, Aunt, Family Friend]]
- Contact phone: [[Caregiver Phone Number]]
- Email: [[Caregiver Email]]
2. Scope of Authority and Effective Duration
Parent/Guardian grants Caregiver full authority to consent to and authorize any and all medical, dental, surgical, diagnostic, therapeutic, and emergency care for the Child, including but not limited to:
- Routine examinations, check-ups, vaccinations, and preventive care.
- Diagnosis and treatment of illness, injury, or other medical conditions.
- Administration of medications, including prescription drugs, over-the-counter medications, and emergency medications such as epinephrine.
- Performance of minor surgical or invasive procedures when deemed medically necessary by a licensed provider.
- Emergency surgery or life-saving procedures when immediate action is required and Parent/Guardian cannot be reached in a timely manner.
- Referral to specialists, physical therapy, mental health services, or other ancillary care.
- Ordering of laboratory tests, imaging studies, and other diagnostic procedures.
This authority is effective from [[Start Date/Time]] until [[End Date/Time]] or until revoked in writing by Parent/Guardian, whichever occurs first. The maximum duration of this Consent shall not exceed [[Maximum Duration e.g. thirty (30) days]] unless extended by written amendment signed by Parent/Guardian.
3. Limitations on Authority
Caregiver shall not consent to any of the following without prior written approval from Parent/Guardian unless required in a true life-threatening emergency:
- Elective or non-urgent cosmetic procedures.
- Experimental treatments or clinical trials.
- Termination of pregnancy.
- Organ donation or other major irreversible procedures.
- Any treatment that Parent/Guardian has previously indicated in writing is against their wishes or religious beliefs: [[Specific Limitations or Restrictions]].
Caregiver shall make reasonable efforts to contact Parent/Guardian before authorizing non-emergency care.
4. Insurance, Physician, and Pharmacy Information
Primary Medical Insurance:
- Carrier: [[Insurance Carrier Name]]
- Policy/Member ID: [[Insurance Policy or Member ID Number]]
- Group number: [[Group Number if Applicable]]
- Policy holder name: [[Policy Holder Name]]
- Phone for verification: [[Insurance Verification Phone]]
Physician / Primary Care Provider:
- Name: [[Primary Care Physician Name]]
- Clinic: [[Physician Clinic or Practice Name]]
- Phone: [[Physician Phone]]
- Address: [[Physician Address]]
Preferred Pharmacy:
- Name: [[Preferred Pharmacy Name]]
- Phone: [[Pharmacy Phone]]
- Address: [[Pharmacy Address]]
- Rx number or notes: [[Pharmacy Notes or Rx Bin/PCN if Known]]
5. Medical History, Allergies, Conditions, and Current Medications
Known Allergies (including medications, foods, latex, environmental):
[[List of Known Allergies or "None known"]]
Current Medical Conditions / Diagnoses:
[[List Current Diagnoses, Chronic Conditions, or "None"]]
Current Medications (name, dosage, frequency, prescriber):
[[Detailed List of Current Medications, Supplements, or "None"]]
Relevant Medical History (surgeries, hospitalizations, immunizations status, special needs):
[[Relevant History or "See attached records"]]
Blood Type (if known): [[Blood Type or "Unknown"]]
Other important medical information or instructions for providers:
[[Additional Instructions e.g. "Child has anxiety around needles; request topical anesthetic if available"]]
6. Emergency Medical Treatment Authorization
In the event of an emergency, Caregiver is authorized to:
- Call 911 or transport the Child to the nearest appropriate medical facility.
- Consent to any emergency treatment, including but not limited to resuscitation, intubation, surgery, blood transfusion, or administration of medication as deemed necessary by attending medical personnel.
- Accompany the Child during transport and remain with the Child until Parent/Guardian arrives or other arrangements are made.
Parent/Guardian agrees to be responsible for all medical expenses incurred under this Consent that are not covered by insurance.
7. HIPAA Authorization and Release of Information
Parent/Guardian authorizes the release of the Child's protected health information (PHI) to Caregiver for the purpose of obtaining and consenting to medical treatment under this Consent.
This authorization includes permission for healthcare providers to:
- Discuss the Child's condition, treatment options, and test results with Caregiver.
- Provide copies of medical records, prescriptions, and discharge instructions to Caregiver.
- Allow Caregiver to sign consent forms, privacy notices, and other required documents on behalf of the Child.
This HIPAA authorization is limited to the duration of this Consent and the specific purpose stated herein. It may be revoked in writing at any time. A photocopy or electronic copy of this signed Consent shall have the same force and effect as the original.
8. Liability and Indemnification
Parent/Guardian acknowledges that Caregiver is acting in good faith as a volunteer or designated temporary guardian. To the extent permitted by law, Parent/Guardian releases and holds harmless Caregiver, healthcare providers, and their staff from any liability arising from care authorized under this Consent, except for acts of gross negligence or willful misconduct.
Parent/Guardian remains fully responsible for all decisions and costs related to the Child's medical care.
9. Revocation
Parent/Guardian may revoke this Consent at any time by providing written notice to Caregiver and any healthcare providers who have received a copy. Revocation does not affect any treatment already provided in reliance on this Consent.
10. Governing Law and Severability
This Consent shall be governed by the laws of the jurisdiction where the Child receives care or where Parent/Guardian resides, as applicable. If any provision is held invalid or unenforceable, the remaining provisions shall continue in full force and effect.
11. Signatures and Acknowledgment
PARENT/GUARDIAN
I have read, understand, and voluntarily grant the authority described in this Minor Medical Consent Form. I certify that the information provided is accurate and complete to the best of my knowledge.
Signature: __________________________________________ Date: ___________
Printed Name: [[Parent/Guardian Full Name(s)]]
Relationship: [[Parent/Guardian Relationship]]
CAREGIVER
I accept the responsibilities and authority granted herein. I agree to act in the best interests of the Child, seek emergency care when necessary, and promptly notify Parent/Guardian of any significant events or treatment provided.
Signature: __________________________________________ Date: ___________
Printed Name: [[Caregiver Full Name]]
WITNESS (optional but recommended)
Signature: __________________________________________ Date: ___________
Printed Name: [[Witness Full Name]]
NOTARY ACKNOWLEDGMENT (if required by state or provider)
State of ________________
County of ________________
On this ___ day of ______________, 20___, before me personally appeared [[Parent/Guardian Full Name(s)]], known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to the within instrument and acknowledged to me that they executed the same for the purposes therein stated.
Notary Public Signature: ________________________________
My commission expires: ________________
(Seal)
Sample template - not professional legal, medical, or financial advice. This form is provided for informational and drafting purposes only. Verify all provisions, required formalities (including notarization and witness rules), and enforceability against the laws of the specific jurisdiction where care will be provided and where the parties reside. Healthcare providers may impose additional requirements. Update information regularly and consult an attorney or healthcare professional for jurisdiction-specific needs. Statutory and regulatory requirements current as of 2026-06; laws change.
Attachments / Exhibits (as applicable)
- Copy of Child's insurance card (front and back)
- Copy of Parent/Guardian photo ID
- Caregiver photo ID
- Child's most recent immunization record or medical summary
- Any prior written limitations or special instructions from Parent/Guardian
Document prepared for use with [[Child Full Name]] under the authority of [[Parent/Guardian Full Name(s)]] for the period [[Start Date/Time]] to [[End Date/Time]].
