Parental Medical Consent Form

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

In most instances medical personnel need consent from a parent before offering medical treatment to a child.

If your child is going to be away from you, there is a risk that you may not be reached quickly in an emergency situation.

A very simple solution is to give a Parental Medical Consent form to a trusted adult who will be with your child. It can also be useful to your child minder to have all the information at hand.

Not only can it facilitate prompt medical treatment, the information on the form could be vital to the attending doctors or emergency staff.

Download your free sample of this legal form and save it to your computer where you can edit it from time to time to produce an up to date document.

Parental Medical Consent Form - Important Information:

  • To avoid administrative hassles during an emergency you should attach a copy of your Medical Aid or Health insurance to your 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 consent form.

We also have a checklist and related legal forms available should you need them:

Copyright Notice

Parental Medical Consent



Full Names:

Identity / Social Security or Other (Specify) number:


Identity / Social Security or Other (Specify) number:

Physical Address:

Contact Details:

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



Birth Date / identifying numbers:

(hereinafter referred to as "the Child")


Full Names:

Identity / Social Security or Other (Specify) number:

Full Names:

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)

SIGNATURE _____________________________(Parent / Guardian)

WITNESS 1:    _____________________________

WITNESS 2:    _____________________________


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.

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