Medical Treatment Authorization and Consent

I, ____________________[Full Legal Name of Parent/Guardian], being the [parent/legal guardian] of ____________________[Child’s Full Name] authorize ____________________[Full Name of Caregiver] to seek, obtain and consent to [routine medical care and treatment/emergency medical care and treatment/ surgery/hospitalization/blood transfusions/dental care and treatment/other] for ____________________[Child’s Full Name] as deemed necessary by a licensed medical or healthcare professional. This authorization is for the time period when my child is in the care of ____________________[Full Name of Caregiver], my child’s ____________________[Relationship to Child (e.g. grandmother, grandfather, aunt, uncle, nanny, baby-sitter, family friend, teacher)] and is effective _________ until __________. 

Child’s Information

Child’s Full Name: ______________________________________________________________
Address: ______________________________________________________________________
Date of Birth: ______________________________ Age: _______________________________

Parent/Guardian’s Information 

Parent’s/Guardian’s Name 1: ______________________________________________________
Address: ______________________________________________________________________
Phone Number (H): _________________________	Phone Number (C): ___________________

Parent’s/Guardian’s Name 2: ______________________________________________________
Address: ______________________________________________________________________
Phone Number (H): _________________________	Phone Number (C): ___________________

Child’s Health Information

Health Conditions (e.g. Asthma, Diabetes): __________________________________________
Allergies (e.g. to Medications, Food): _______________________________________________
Prescription Medications: ________________________________________________________
Date of Last Tetanus Injection/Booster: _____________________________________________

Child’s Medical Care and Insurance Information

Physician/Pediatrician: ______________________	Phone Number: ______________________
Dentist/Orthodontist: _______________________	Phone Number: ______________________
Preferred Medical Facility: _______________________________________________________
Insurance Company: ____________________________________________________________ 
Policy/Group Number: _______________________	Policy Holder: _______________________

SIGNATURE OF PARENT/GUARDIAN

Signature   	_____	Date _______________________________
Print Name _______________________________

WITNESS 

Witness Signature   	_____	Date _______________________________
Print Name _______________________________
Address   	____________

Witness Signature   	_____	Date _______________________________
Print Name _______________________________
Address   	____________

NOTARY ACKNOWLEDGMENT

State of _______________
County of _____________

On this   ___ day of _______________ in the year 20___ before me, 	_______, appeared   	_______, who is personally known to me or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to this instrument, and acknowledged that he or she executed it.

Notary Seal

(Signature of Notary Public)

My Commission Expires: _______________