Medical Treatment Authorization And Consent - Arts Of The Pamlico Page 3
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4Child Medical Consent (Rev. 1337B55)
- Child's pertinent medical history which may include
GENERAL INSTRUCTIONS
health conditions, allergies, medications, and vaccine
information
As a parent or legal guardian, at some point in time, you
will likely need to have other people provide care to your
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Names and contact numbers of your child?s regular
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minor child. This may include regular daycare, family
medical providers which may include pediatricians,
members who help out occasionally, or perhaps a
dentists, or preferred medical facilities
babysitter for special occasions. When someone else is
taking care of your child it is especially important to plan
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Medical insurance information including the name of the
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ahead for potential medical needs and emergency
insurance company, the policyholder?s name, and the
situations. A Medical Treatment Authorization and
policy/group number.
Consent Form allows you to ensure proper medical care
is given to your child, even when you cannot be there in
WHEN SHOULD THIS FORM BE USED?
person to express your wishes and consent.
A Medical Treatment Authorization and Consent Form
WHAT IS A MEDICAL TREATMENT
specifically identifies the caregivers who are allowed to
AUTHORIZATION AND CO NSENT FORM?
make medical decisions for your child in your absence, as
well as dictating which types of medical decisions can be
A Medical Treatment Authorization and Consent Form
made by the appointed caregivers. This form will also
specifically identifies the caregivers who are allowed to
include other important data, such as your child?s
make medical decisions for your child in your absence, as
identifying information, your name and contact
well as dictating which types of medical decisions can be
information, any pertinent medical history, and information
made by the appointed caregivers. This form will also
regarding your family?s medical providers and medical
include other important data, such as your child?s
insurance. Finally, the form includes your signature, the
identifying information, your name and contact
signature of two witnesses, and certification by a notary
information, any pertinent medical history, and information
public.
regarding your family?s medical providers and medical
insurance. Finally, the form includes your signature, the
WHAT TYPES OF MEDICAL TREATMENT CAN
signature of two witnesses, and certification by a notary
BE SPECIFIED?
public.
You may authorize the caregiver to make decisions about
WHAT SHOULD BE INCLUDED?
specific types of medical care, including:
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- Full legal name of all parents or legal guardians
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Routine examinations and check ups
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- Child's full legal name
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Emergency medical treatment
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- Caregiver's full legal name (in most states, it will be
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Emergency medical transportation
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important that this caregiver is at least 18 years of age)
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Diagnostic imaging (x-rays, CT scans, MRIs)
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- Caregiver's relationship to the child (e.g. grandparent,
nanny, teacher)
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Medication administration
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- Types of medical care you are authorizing
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Anesthesia and surgical procedures
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- Time period in which this consent will be effective
OTHER NAM ES FOR CHILD MEDICAL
CONSENT
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- Home address for child and parents or legal
guardians (if different)
This form may also be referred to as:
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- Child's date of birth and age
Child Medical Consent Form, Caregiver Medical Consent
Form, Medical Authorization for Minor, Medical Treatment
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- Parent or legal guardian's best contact information
Authorization Form, Consent for Medical Treatment of a
Minor, Authorization to Consent to Medical Treatment
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Child Medical Consent (Rev. 1337B55)
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