Parental Medical Consent Form

[?] Subscribe To This Site

Parental Medical Consent Form

Your Free Parental Medical Consent Form is crucial when it is impossible to get hold of parents in an emergency situation.

It can also be useful to issue instructions to a child minder or when a child is going on an excursion. On occasion you may also need a free Temporary Guardianship Form or a separate Parental Travel Consent Form.

Sidebar: A Medical Power of Attorney can be issued to appoint an Agent to make health care or personal care decisions on your behalf in the event that you become incapacitated.

It's easy and straight forward - download your Free Parental Medical Consent Form and Get it in Writing!

Your Free Parental Consent Forms can be copied into any word program where you can edit it to suit your requirements.

IMPORTANT INFORMATION

* To avoid administrative hassles during an emergency you should attach a copy of your Medical Aid or Health insurance to your Free Parental Medical Consent Form;

* Make sure you initial wherever alterations are made with full signatures at the end;

* Witness signatures must be by independent persons and not by anybody listed on the parental medical consent form.

parental medical consent form

Parental Medical Consent

THE PARTIES TO THIS AGREEMENT ARE:

THE PARENT(s) / GUARDIAN(s)

Full Name and Surname:

Identity / Social Security or Other (Specify) number:

Full Name and Surname:

Identity / Social Security or Other (Specify) number:

Physical Address:

Contact Details:

(hereinafter referred to as "the Parent / Guardian")

THE CHILD

Full Name and Surname:

Birth Date / identifying numbers:

(hereinafter referred to as "the Child")

THE TEMPORARY GUARDIAN(s)

Full Name and Surname:

Identity / Social Security or Other (Specify) number:

Full Name and Surname:

Identity / Social Security or Other (Specify) number:

Physical Address:

Contact Details:

(hereinafter referred to as "the Temporary Guardian")

1. I authorize the Temporary Guardian to administer general first aid treatment for minor injuries or illnesses experienced by the Child except where any such first aid treatment is specifically excluded hereunder:

2. I authorize the Temporary Guardian, in the event that I cannot be contacted or if any urgency dictates, to act in loco parentis for the Child in respect of any circumstances, including any accident or illness, which may necessitate medical treatment, including surgery, and on my behalf to authorize any such treatment or surgery which they, in their sole discretion, (which discretion shall not be unreasonably exercised), may deem necessary. Medical treatment for the Child may also include dental surgery, x-ray, blood transfusion, anesthetic and medication provided any such medical treatment is performed by a duly licensed practitioner. I hereby accept full liability for all costs incurred through such medical treatment for the Child.

3. Persons responsible should please note the following: (Please state aspects eg. allergies, tendency towards abnormal bleeding, epilepsy, etc.)

Present prescribed, or other medication that is being administered:

4. The following information is essential in case of medical treatment or hospitalization:

4.1. Name and Address of Employer:

4.2. Medical Aid / Insurer:

4.2. Policy Number:

5. I declare that I am the legal custodian of the Child and that I have legal authority to grant medical consent to the Temporary Guardian for the Child.

6. Unless inconsistent with the context, words signifying the singular shall include the plural and vice versa.

7. This medical consent will be in effect from the _______ day of ___________________20__

until the _____ day of ______________________20__

Signed at ______________________on this ______day of _________________20____

SIGNATURE _____________________________(Parent / Guardian)

WITNESS 1: _____________________________

WITNESS 2: _____________________________

Return from Parental Medical Consent Form to Free Legal Documents

Your parental medical consent form can be copied at No Cost into any word program. It will give you peace of mind knowing a trusted adult can make decisions on your behalf in an emergency situation.