Medical Consent Form for Minor
Review this draft for accuracy, local requirements, and caregiver instructions before signing.
MEDICAL CONSENT FORM FOR MINOR Child information Child name: Avery Johnson Date of birth: 2018-04-12 Parent or legal guardian Name: Morgan Johnson Phone: 555-0134 Email: morgan@example.com Authorized temporary caregiver Name: Taylor Lee Role: Babysitter Phone: 555-0198 Authorization Scope: Emergency care only Valid from: 2026-06-16 through 2026-07-16 I authorize the temporary caregiver named above to seek medical evaluation and treatment for my child if I cannot be reached in time. This authorization includes: - Emergency room or urgent care treatment - Ambulance transport if medically necessary - Sharing insurance and medical history with providers Medical conditions: - Asthma. Uses rescue inhaler as directed. Allergies: - No known drug allergies. Medications: - Albuterol inhaler - kept in front pocket of backpack. Insurance and providers Insurance provider: Example Health Policy or member number: ABC123456 Physician: Dr. Priya Shah Physician phone: 555-0109 Preferred hospital or clinic: City Children's Hospital Emergency contact Jordan Johnson, 555-0177 Special instructions Call parent first when possible. If breathing symptoms worsen, seek urgent care immediately and bring inhaler. Guardian signature: ______________________________ Printed name: ______________________________ Date: __________________ Caregiver acknowledgement: ______________________________ Date: __________________