Child Medical Consent Form

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The child medical consent form grants an authorized member of hospital staff to operate on and treat a child. The document once filled out, ensures that the parent or guardian allows the doctors, nurses and other hospital staff to use their judgment as they see fit to treat the child to the best of their ability. The signed form indicates that the parent/guardian is responsible for all charges connected to the treatment and diagnosis of the child in question.

How to Write

Step 1 – Download in Adobe PDF (.pdf).

Step 2 – Supply your name, and check off your relationship with the child. Next, enter your child’s name and gender along with their age.

Step 3 – Read to two (2) statements, then give them a name of the person/agency to whom you are giving your consent. Enter again the name of the child and the period in which they will be under the aforementioned person/agency’s care.

Step 4 – Enter your name again, followed by the below information.

  • Address
  • Telephone number
  • Family physician name
  • Pediatrician name
  • Surgeon name
  • Orthopedist name

Step 5 – Supply the name of the health insurance carrier, the group number, and the agreement number. If the child has any allergies, list them where applicable. Enter the date of the last tetanus booster and any medications the child is currently taking.

Step 6 – Before printing off the form and providing your and a witness’s signature, enter where you can be reached at in case of emergency. Supply this form to agency/individual who will be caring for your child.