Medical Consent for the Treatment of a Minor

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The medical consent for the treatment of a minor is a simple but important document that grants authority to a designated adult to care for the child of the signatory in the case of a medical emergency. The authority is temporary, the start and end date will be provided within the document. As it is not always possible or practical to contact the parents or legal guardians of a child when there is a medical emergency, this document allows the designated adult to provide minor first aid and seek emergency treatment as they deem necessary.

How to Write

Step 1 – Download in Adobe PDF.


Step 2 – Once the form has been downloaded, provide the minor’s full name, home address, date of birth, and gender.

Step 3 – Information for medical treatment must be supplied to the designated adult. This will include the child’s physician, the physician’s location of practice, and the physician’s phone number. The insurance plan name and policy number must be supplied as well. If the child has allergies to medication, they should be specified. All conditions for which the child is receiving treatment and any other applicable medical info must be provided in the final two fields.

Step 4 – The designated adult’s name can be entered in the paragraph field. Provide the date for the end of authorization, and the day the document is being signed. Sign the form, and print your name. A witness must be present and do the same.