Child Medical Consent Form
A child medical consent form is an important document to have in situations where your child requires medical attention in your absence. This child medical consent form enables a trusted care- giver to seek medical attention for your child in cases where you are unavailable.
Sample Child Medical Consent Form
Name of child: __________________________ Age: _________________________
Date of birth: ___________________________ Grade: ________________________
Mother’s name: _________________________ Mob no: ______________________
Occupation: ____________________________ Work contacts: _________________
Father’s name: __________________________ Mob no: ______________________
Occupation: ____________________________ Work contacts: _________________
Please list any known allergies, ailments or treatments your child currently has.
Allergy Type of surgery Medication Other
________________ _____________________ ________________ ____________
________________ _____________________ ________________ ____________
I _____________________ (name of parent) give my consent to
___________________________ (name of teacher, babysitter, care- giver etc) to seek
Medical help for my child _________________________ (name of child) in my absence.
Parent’s sig: ____________________________ Date: _________________________
Name of witness: ________________________ Sig: __________________________
Category: Medical Forms
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