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Minor Consent Policies
The laws around a minor’s ability to consent to medical treatment on their own vary widely from state to state. They are often determined by factors such as the minor’s age, the type of treatment, whether it’s an emergency, or marital status.[1]
Parents can learn more about their state’s minor consent policies by reviewing the laws table on the American Academy of Pediatrics website.
Emergency Situations – In emergencies where there is insufficient time to obtain consent, physicians may administer medical treatment to the minor without the grandparent’s authorization.[2]
How to Use the Consent Form (4 Steps)1. Fill out the Consent FormIf a parent/guardian would like a grandparent to manage their child’s medical needs when they’re unavailable, the first thing they’ll need to do is prepare a consent form that contains the following:
2. Supply Additional Details (Optional)To assist medical staff with the child’s treatment, parents and guardians may want to include the following details in the consent form:
3. Provide SignaturesThe parents or guardians must sign and date the document to make it effective. It is strongly recommended that the form be notarized and signed by a witness, as some medical facilities may require it to confirm the document’s authenticity.
4. Present Form to Healthcare ProvidersCopies of the completed consent form should be provided to the child’s healthcare providers to notify them of the grandparent’s authorization. The grandparent should also keep a copy to prove their authorization when seeking medical treatment for the child. |
Sample
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GRANDPARENT MEDICAL CONSENT FORM
I/We, [NAME OF PARENT(S) OR GUARDIAN(S)], the parent(s) or legal guardian(s) of [CHILD’S NAME], residing at [CHILD’S ADDRESS], born on [CHILD’S BIRTH DATE], do hereby consent and allow [GRANDPARENT’S NAME] to handle any type of medical care for my/our child including, but not limited to, the administration of anesthesia determined by a physician, surgery, and any other care recommended or deemed necessary for the welfare of my/our child in my/our absence.
This authorization is effective [EFFECTIVE DATE] and expires on [EXPIRATION DATE].
Patient Signature: _____________________________ Date: ________
Printed Name: _____________________________
Parent/Guardian Signature: _____________________________ Date: ________
Printed Name: _____________________________
Witness Signature: _____________________________ Date: ________
Printed Name: _____________________________
This consent form should be taken with the child to the hospital or physician’s office when the child is taken for treatment. The following additional information will assist in treatment if it can be furnished with the consent form, but is not required:
Father’s Phone: [FATHER’S PHONE] Mother’s Phone: [MOTHER’S PHONE]
Food and Drug Allergies: [LIST CHILD’S ALLERGIES]
Medications: [LIST CHILD’S MEDICATIONS]
Blood Type: [CHILD’S BLOOD TYPE]
Child’s Physician: [PHYSICIAN’S NAME] Physician’s Phone: [PHYSICIAN’S PHONE]
Insurance Provider: [INS. PROVIDER’S NAME] Policy Number: [POLICY #]
Other Pertinent Information: [OTHER PERTINENT INFORMATION]
ACKNOWLEDGMENT
| A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. |
State of ___________)
County of ___________)
On ___________, before me, ____________________, personally appeared ____________________, who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity, and that by his/her/their signature(s) on the instrument the person(s) executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of ___________ that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
Notary Signature: _____________________________ (Seal)
Printed Name: _____________________________
My Commission Expires: ___________