MAKE YOUR FREE Consent for Medical Treatment of a Minor
What is a Consent for Medical Treatment of a Minor?
A Consent for Medical Treatment of a Minor document allows you to specify the the scope of permission to treat your child, from allowing for the use of basic first aid or emergency medical treatment only, to approving the use of general anesthesia. This document also enables you to provide information about your child's physician, preferred hospital, insurance, and prescription medications. Due to the broad possibility of medical needs, it is important to choose someone you trust to make these decisions.
When to use a Consent for Medical Treatment of a Minor:
- You want to give limited consent to someone else to obtain medical treatment for your child.
- You have a regular, trusted daycare provider who you want to be able to request medical attention for your child if it becomes necessary while the child is in their care.
- Your child will be in the temporary care of someone else such as other family members, school teachers or coaches, church groups or travel agency.
Sample Consent for Medical Treatment of a Minor
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MEDICAL TREATMENT AUTHORIZATION FOR A MINOR
I, , the authority to obtain medical treatment for the following child(ren):
| Name of Child: |
| Birthdate: |
The above care provider(s) are authorized to:
| Other Information: |
This grant of temporary authority shall begin on , and shall remain effective
Dated:
| By: | Date: |
| , |
| Preferred Phone Number: |
| Alternate Phone Number: |
, COUNTY OF PARISH OF
On this _____ day of ____________________, _____, before me, ______________________________, the undersigned officer, personally appeared ______________________________, known to me (or proved to me on the oath of ______________________________) to be the person who is described in and who executed the within and foregoing , and being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.
Before me, a Notary Public (or justice of the peace) in and for said county, personally appeared the above named ______________________________, who acknowledged that he/she did sign the foregoing , and being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief. In testimony whereof, I have hereunto subscribed my name at ________________________________, this _____ day of ____________________, _____.
The foregoing was acknowledged before me this _____ day of ____________________, _____, by ______________________________, who, being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.
The foregoing was acknowledged before me, by means of ☐ physical presence or ☐ online notarization, this _____ day of ____________________, _____ by ______________________________, who is personally known to me or who have produced ________________________________ as identification, and being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.
This was acknowledged before me on this _____ day of ____________________, _____ by ______________________________, who, being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.
On this _____ day of ____________________, _____, before me personally appeared ______________________________, to me known to be the person described in and who executed the foregoing , and, being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.
On this _____ day of ____________________, _____, before me, ________________________________, personally appeared ______________________________, known to me (or satisfactorily proven) to be the persons whose names are subscribed to the within , and, being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.
On this _____ day of ____________________, _____, before me, the undersigned, Notary Public for the State of Vermont, personally appeared ______________________________, to me known (or to me proved) to be the identical person named in and who executed the above , who, being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.
The foregoing instrument was acknowledged before me this _____ day of ____________________, _____, by ______________________________, who, being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.
In witness whereof I hereunto set my hand and official seal.
_________________________________
Notary Public
Signature of person taking acknowledgment
_________________________________
Name typed, printed, or stamped
Title (and Rank)
_________________________________
Title or rank
My commission expires _____________
_________________________________
Serial number (if applicable)
Serial number, if any
Notary Address:
_________________________________
_________________________________
_________________________________
_________________________________
Consent for Medical Treatment of a Minor FAQs
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Does a Consent for Medical Treatment of a Minor document need to be notarized?
Yes, in order to be legally binding, a Consent for Medical Treatment of a Minor document needs to be notarized. Both parents may want to sign the document, if possible.
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What are the 4 types of consent?
The four types of consent are:
- Implied consent
- Express consent
- Informed consent; and
- Unanimous consent
This Consent for Medical Treatment of a Minor document is an example of express consent because it is giving an authorized individual permission to provide express consent to medical care or treatment for your child(ren).
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What is the difference between a Medical Consent Form and a Travel Consent Form?
The primary difference between these documents is marked by the authorization type, travel vs. medical. A medical authorization is specific to your child's healthcare needs, while travel authorization allows your child to travel under the care of whomever you, as the parent or guardian, name in the Travel Consent document.
