Child Medical Consent Form

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A Child Medical Consent Form, or Child Medical Release Form, is a legal document used to allow another adult to make healthcare decisions for your child.

Child Medical Consent forms are usually used when your child is temporarily in the care of another adult, and you want to make sure the adult can help your child in the event they need medical attention.

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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, policyholder
  • 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.


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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 daycare 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.

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


    1. 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


    1. 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



A Child Medical Consent Form 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

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

blue person icon1. 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.

stethoscope-icon2. 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

information icon3. 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

question-mark4. 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

Specification: Child Medical Consent Form


Number of pages

Type of Document

Written in the year

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