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Authorization for medical attention

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Authorization for medical attention
February 15, 2019 Anniversary Wishes 5 comments

Use our attorney-drafted Child Medical Consent form for parents to Authorization to Consent to Medical Treatment; Authorization for Minor's.

Table of Contents

  1. Download a Free Child Medical Consent Form
  2. The Basics: What is a Child Medical Consent Form?
  3. When Do I Need One?
  4. The Consequences of Not Using One
  5. The Most Common Situations when a Consent form is Needed
  6. What Should be Included

1. Download a Free Child Medical Consent Form

Click here to begin your download

2. The Basics: What is a Child Medical Consent Form?

A Child Medical Consent form is a written document authorizing another adult to make healthcare decisions for a minor child. For example, a grandparent, aunt, uncle, nanny, babysitter, or family friend may be taking care of your kid when an emergency occurs.

This form ensures that person can get your child proper medical care. If a parent or legal guardian is not traveling with their kid, the document is often used with a Child Travel Consent Form.

A simple Child Medical Consent form will identify the following basic elements:

  • Parents: name and contact information of parent(s) or legal guardian(s)
  • Child: name, address and date of birth for each minor
  • Caregiver: name of responsible adult authorized to make decisions for some time
  • Medical History: child’s health condition, allergies, prescriptions, and vaccines
  • Healthcare Provider: name/number of physician/pediatrician and dentist/orthodontist
  • Health Insurance: name/number of insurance, policy/group number, policy holder
  • Signature: signed by the child’s parent or legal guardian

As a reference, people call this form by other names:

  • Authorization to Consent to Medical Treatment
  • Authorization for Minor’s Medical Treatment
  • Caregiver Medical Consent Form
  • Consent for Medical Treatment of a Minor
  • Consent to Treat Minor Children
  • Emergency Medical Consent Form
  • Medical Authorization for Minor
  • Medical Treatment Authorization Form
  • Parental Medical Consent Form

Child Medical Consent PDF Sample

The sample child medical consent below details an agreement between the parent, ‘Michael B Knapp’, and the child’s teacher, ‘Wade L Jobe.’ Michael B Knapp agrees to Wade L Jobe seeking medical aid for the child, Evelyn J Knapp, when she is under his care.

Child Medical Consent

3. When Do I Need One?

This consent form is commonly used when a parent or legal guardian has entrusted another person to temporarily take care of their kid.

A consent form is needed under these circumstances:

  • Child is a minor — under the age of 18 years old
  • Child is traveling with another person or group
  • Child is with a babysitter or day care center
  • Chaperone or trip leader is taking care of your kid
  • Parent or guardian is temporarily away on work or business trips

The reality of life means parents may not be with their child if an emergency occurs. This form allows parents to designate a responsible adult to authorize medical treatment for their kid.

4. The Consequences of Not Using One

When you are not with your kid, a Child Medical Consent form can give you the peace of mind that your son or daughter will receive prompt medical care.

Without this form, the following preventable suffering could occur:

Consequences Suffered by Parent/Adult

Consequences Suffered by Child


  1. Loss of time

    • Caretaker is unable to make emergency decisions in a timely manner

  2. Mental anguish

    • Parent is frustrated that healthcare professionals do not trust their child’s caretaker
    • Caretaker is unauthorized to make medical decisions

  1. Loss of time

    • Unnecessary delay as healthcare professionals struggle to contact unavailable parent or guardian

  2. Mental anguish

    • Upset that they are not able to to receive needed medical treatment or care

    • Confusion as to why healthcare professionals are not listening to their caretaker


5. The Most Common Situations when a Consent form is Needed

It should be used if the child is:

  • Home with a babysitter or family member
  • Traveling with an authorized caretaker
  • Staying at a child day care facility
  • Taken care of by a nanny or au pair while parents are at work

Choose an authorized caretaker who understands your moral beliefs and shares your concern for the best interest of your child.

6. What Should be Included

Our sample Child Medical Consent form asks you easy questions that help you fill out the form.

1. Who is the authorized caretaker?

The parent or legal guardian designates another adult to be the authorized caretaker of their kid in cases of medical emergencies. The temporary guardian understand the parents’ wishes about medical treatment for their child.

2. What is the child’s medical history?

The parent or legal guardian should detail the minor’s health background, for example:

  • Health conditions like asthma, diabetes, or pacemaker
  • Allergies to antibiotics, medicine, or food
  • Prescription of medications currently being taken
  • Date of last tetanus injection or booster
  • History of vaccines

Listing your child’s health background helps healthcare professionals diagnose a condition and make effective medical decisions.

3. What medical treatments are allowed?

Parents can authorize the caregiver to make certain medical care decisions for some time:

  • Administer medication and prescriptions
  • Anesthesia and surgical procedure
  • Blood transfusions
  • Dental care and treatment
  • Diagnostic imaging  (X-rays, CT scans, MRIs)
  • Emergency medical care and treatment (i.e. CPR, surgery, hospitalization)
  • Emergency medical transportation (i.e. ambulance)
  • Routine examinations and check ups

Specify when (start and end date) the caretaker has the power and authority to make medical decisions of the minor.

4. What other details should be included in a Child Medical Consent?

The form may also include the following details:

  • Assurances that the parent or guardian is legally allowed to make such authorizations
  • Best interests of the child and the child’s health and well-being is a priority
  • Financial responsibility will remain with the parents and the minor’s health insurance
  • Governing law of the state that will apply with respect to medical services
  • Religious or moral beliefs that should guide the caretaker and healthcare professionals

Permission for Treatment: The health history provided on this form is correct to the permission and authorize the provision of emergency medical treatment for .

Why You Should Prepare a Medical Release Form for Your Child

authorization for medical attention

Grandparents and other elders are playing a larger and larger role in the care of young children in our community.  In Philadelphia alone, advocates estimate that more than 60,000 children are being raised by relative caregivers, primarily grandparents and other elderly family members.  This accounts for 1 in 6 children in our community.

These elders — known as kinship caregivers — have assumed the role of parent to ensure that these children receive medical care, an education, and the stability, affection, and sense of family they need to survive.    Many other grandparents also care for children while parents are at work, for a few hours when needed, or during a difficult period such as a divorce.

In all such instances, older adults may need to take a child to a doctor for either routine medical care, such as check-ups, or for emergency treatment.  If the caregiver is not the legal guardian or custodian, they are not able to give consent for medical, dental or mental health treatment.  Pennsylvania’s Medical Consent Act provides a tool that can help resolve these problems.

The Medical Consent Act allows a parent or legal custodian to authorize another person to consent to medical, dental or mental health care for children by completing and signing a simple document.  The relative or family friend that is named may consent to a child’s medical, dental, surgical, developmental, and/or mental health examination or treatment, and may have access to any and all records, including insurance records regarding such services.

The Medical Consent Act creates a procedure where children can get the necessary medical care without affecting the rights of the full-time caregiver, whether it be the child’s parent or a grandparent who has legal custody.  The Act also protects physicians and insurance providers.  Any person, facility or insurer who in good faith relies on a medical consent from will not be subject to civil or criminal liability for treating a minor.

What is the Importance of Medical Consent?

A grandparent or anyone raising a child who has already obtained legal custody through the court system already has the right to consent to that child’s medical care.
Many grandparents raising grandchildren or other caregivers have only informal custody, not legal custody, or assist the parents in raising the child at certain times of the day.  For example, a grandmother may serve as caregiver during the day while a child’s mother is on the welfare-to-work program.  In addition, a parent with substance abuse or other problems may ask an elderly relative to care for a child temporarily, but fails to return for a lengthy period of time — or never at all.  In these instances, the medical consent document allows the caregiver to consent to medical treatment and medical care for children designated in the document.  Designating authorization for medical consent to a caregiver does not revoke the birth parents’ rights.

It is important to obtain a medical consent from the birth parent before a medical issue or emergency arises.  It can take time to find a birth parent if the caregiver has limited contact with the parent.  Having a medical consent prevents the hassles of going to court and requesting emergency legal custody.  When a grandparent or other elder becomes a primary caregiver, the medical consent should be completed immediately.

How Do Caregivers Get Medical Consent?

The parent or legal caregiver giving the authorization may complete a medical consent form, available from many local organizations, or simply write a statement.  The form or statement must contain the following:

  • identity of the caregiver
  • the names and dates of birth of the children at issue
  • a description of the medical treatments for which authorization is given
  • a statement that there are no court orders in effect which would prohibit the authorization
  • the signatures of the parent, legal guardian, or custodian, in the presence of two witnesses.  (The caregiver receiving the consent cannot be one of the witnesses signing.)

The Medical Consent or written statement is not a permanent document.  It can be revoked at anytime.  The parent can revoke consent by notifying the caregiver, health care and insurance providers in writing.  Parents, caregivers, heath care and insurance providers can put a time limit on the consent; however, this is not required by law.

The medical consent form may not be used if a child is in the custody of the county children and youth agency.

SeniorLAW Center assists older adults raising young children in many ways, including providing legal advice, counsel, and information, direct legal representation in custody and support matters, and referral to other available resources and services.

Seniors in Pennsylvania can discuss concerns about kinship care, raising grandchildren or other minor children by calling our Pennsylvania SeniorLAW HelpLine at 1-877 PA SR LAW (1-877 727-7529).  Seniors in Philadelphia can also call SeniorLAW Center’s telephone intake line 215-988-1242.  Click here to view how to access our services.

Seniors who are involved with or want to care for children at risk of abuse or neglect or in the DHS system Philadelphia can contact our FOSTERING CONNECTIONS TO KINSHIP CARE PROJECT COORDINATOR

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Permission To Treat

authorization for medical attention

In an emergency, you may not be able to tell your care providers about your complete medical history or you may be unavailable if your child needs attention in the emergency department of your local hospital. These forms are here to help you get the care you need in a life-threatening situation.

Emergency Information Form for Children with Special Health Care Needs
ACEP and the American Academy of Pediatrics offer parents of children with special health care needs an Emergency Information Form – a tool to transfer a child's complicated medical history and critical information in the event of an acute illness or emergency injury.

Personal Medical History
If you or a member of your family has a medical emergency, the physician will need a complete medical history. Complete this form (don’t forget to update it) and keep it in an easily accessible place. This form is convenient to use while you’re traveling.

Consent to Treat FormThis Consent to Treat Form gives a physician permission to treat your child when he or she is in someone else’s care. Complete it and make sure grandparents and babysitters have access to it.

Formas de Consentimiento (Spanish Consent to Treat Form)

This article contains information on a way certain non-parents can be allowed to consent to medical treatment of a minor child. This article was developed by the.

Free Child Medical Consent Form

authorization for medical attention

Most of the time, kids' accidents and emergencies are entirely unpredictable and unexpected. Of course, you don't plan on your child falling and breaking a bone while he's with a babysitter, or needing emergency care for an allergic reaction when he's staying with grandma. These incidents catch caregivers off guard, too! That's why you need to provide a medical release form to anyone caring for your child in your absence. This simple form gives clear, irrefutable consent for medical treatment.

If you cannot be reached by phone, text, or email, the form can be used in the event that your child suffers an injury that requires medical treatment. It is one of the most important steps any parent can take to ensure your children are safe, even when you're not around.

Why You Need to Sign a Medical Release Form for Your Minor Child

Hospitals have to treat everyone who comes through the door, right? That isn't necessarily true, especially when it comes to children. Many urgent care facilities and emergency rooms will not treat minor children unless:

  • A parent is present
  • A parent has given consent in writing
  • The child's life is in danger

That means that injuries or illnesses that aren't life-threatening may not be treated. Say your son suffers a broken bone on the playground while you're at work or out of town. You don't want him to have to wait for treatment—including pain relievers—until you can be reached. 

Printable Permission to Treat Form

The St. Louis Children's Hospital has a free "Permission to Treat" form that you can download and print. It is a simple, one-page document that includes all of the relevant information caregivers and medical staff need to treat your children when you're not present.

  1. Start by printing one copy of the medical release form for each child.
  2. Fill out the form completely. If you share custody or parenting responsibilities, be sure to include the other person's information and let them know that you're taking this step.
  3. Have the form notarized so it is legally binding. Do not sign any copies of your kid's medical consent forms until you're in the presence of the notary public. Signing them too early will nullify the entire process and you'll have to start over.

If you share legal custody with your child's other parent, make arrangements to have the form notarized together so you can both sign it. This is the best way to indicate that you both give consent for your child to receive treatment in the event that neither of you can be reached in an emergency.

Ensure the Medical Release Form Is Accurate and Legal

This is an important document; double-check that everything's correct. There are a few additional steps you should take to ensure your child has access to health care if you are not available.

  • Verify all of the phone numbers on the form.
  • Include primary and secondary insurance information.
  • Consider having multiple copies notarized for each child.
  • Keep notarized copies (not photocopies of the original) in multiple places. File one at your home, at your ex's home, and place one in your child's backpack. It's also best to keep a copy anywhere your child frequents on a regular basis, such as a babysitter's house.
  • Review the forms annually. If key information has changed, print new copies and start over. It's vitally important that all of the information be accurate and up to date.

Thanks for your feedback!

WATCH THE VIDEO ON THEME: How to clinic chart forms and informed consent Dr Vizniak

A Caregiver Consent Form, prepared in advance, assures that the caregiver will be able to make medical decisions guided by health care professionals in your.

authorization for medical attention
Written by Dairisar
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