MEDICAL CONSENT FORM FOR A MINOR
Authorization for another adult to consent to medical care

THE CHILD
Full name: [Child's full name]
Date of birth: [Date]
Home address: [Address]

PARENT OR LEGAL GUARDIAN
Name: [Full name]
Relationship to the child: [Mother, father, or legal guardian]
Legal authority: [Parent with decision-making authority, or guardian with a copy of the court order or guardianship document attached]
Other parent or guardian: [Name and phone, and whether they agree with this form, or not applicable]
Court orders: [Any order that limits who makes medical decisions for the child, or none]
How to reach me: [Every phone number, email, and messaging app]
Where I'll be: [Place and time zone, and times I can't be reached, such as flights]

AUTHORIZED ADULT
Name: [Full name]
Relationship to the child: [Grandparent, relative, caregiver, coach, teacher, or trip leader]
Phone: [Mobile number, and any other number]
Where the child will be: [Address, or the trip or camp location]
Photo ID they'll carry: [Driver's license, passport, or other]
Backup adult: [Name, relationship, and phone, or none]

DATES
Valid from: [Start date and time]
Valid until: [End date and time]

WHAT THIS FORM COVERS
While I can't be reached, the adult named above may consent to:
Routine care: [Yes or no: check-ups, minor illness or injury, prescriptions]
Urgent care: [Yes or no: walk-in or urgent care visits, X-rays, stitches, splints]
Emergency treatment: [Yes or no: emergency department care, hospital admission, anesthesia and surgery that can't wait]
Not covered: [Care I don't authorize, such as planned surgery, vaccinations, or non-urgent dental work, or none]
Call me first for: [Decisions I want to make myself when there is time]
Medicines the adult may give: [Over-the-counter medicines at the dose on the package, regular medications, and anything a clinician prescribes during this time]

THE CHILD'S HEALTH
Conditions: [Ongoing conditions, or none]
Allergies: [Medicines, foods, latex, or insect stings, with the reaction, or none known]
Medications: [Name, dose, and when it's taken, or none]
Care plans attached: [Asthma action plan, allergy emergency plan, seizure plan, or none]
Vaccinations: [Up to date or not, and the date of the last tetanus shot]
Weight: [Weight and the date measured, for medicine doses]
Other: [Past surgeries, devices, diet, or anything else a clinician should know]

HEALTH COVERAGE AND USUAL CARE
Health plan: [Plan or insurer, member number, and the plan holder's name and date of birth]
Copy of the plan card: [Front and back attached, or not attached]
Usual clinician: [Name, practice, and phone]
Pharmacy: [Name and phone]

SIGNATURES
I am this child's parent or legal guardian and have the authority to sign this form. In an emergency, clinicians will give the treatment needed to save a life or prevent serious harm without waiting for consent. I can cancel this form at any time by telling the authorized adult and anyone holding a copy.
Parent or guardian: [Signature, printed name, and date]
Second parent or guardian: [Signature, printed name, and date, if the organization asks for both]
Authorized adult: [Signature, printed name, and date]
Child: [Signature of an older child or teen, if you choose, to show they know about this form]
Witness or notary: [Only if the school, camp, or care provider requires one: name, signature, date, and stamp]

CLINIC VERSION: CONSENT TO TREAT A MINOR
For a parent or guardian to sign when a child registers with the practice

Practice: [Practice name, address, and phone]
Child: [Full name and date of birth]
Parent or guardian: [Name, relationship, phone, and legal authority]
Other parent or guardian: [Name, phone, and any court order that limits medical decisions, or none]
Consent: I consent to the clinicians at [Practice name] examining, testing, and treating my child for routine and acute care. Before any procedure, new medication, or vaccination, the clinician will explain it and ask for agreement.
Adults who may bring my child: [Names, relationships, and phones of adults who may consent to routine visits, or none]
Time alone with the clinician: [How the practice sees teens alone for part of a visit, and what stays private]
What my child can consent to alone: [The care young people can consent to themselves where you practice, explained to the parent]
Valid until: [Renewed each year at registration, or until I withdraw it]
Signed: [Parent or guardian's signature, printed name, and date]
Witness: [Staff name and date, if the practice uses one]

IF THE FORM IS USED
For the treating clinician's note
Form seen: [Date, time, who brought the child, photo ID checked, copy kept]
Parent or guardian called: [Time, number used, and the outcome]
Consent from: [The authorized adult, the parent by phone, or emergency treatment given without waiting]
Care given and follow-up: [Treatment, anything the form excluded, and when the parent was updated]