When It’s Used

Parents or legal guardians can use a medical consent form when their child is being cared for by another person and cannot be contacted. For example, if the minor child is injured at summer camp and the parents cannot be contacted to consent to treatment, the staff may use this form to authorize emergency treatment.

It should be noted that the age at which minors can consent to medical treatment varies from state to state, and a minor child consent form may not be required. For example, in Alabama, minors 14 years of age and older can consent to medical care without the need for the consent of an adult.^[1]

The American Academy of Pediatrics provides a guide that details the age of medical consent for minors in each state.

How to Complete a Minor Medical Consent Form (4 Steps)

1. Identify the Individuals

The form should include the names and phone numbers of each parent and legal guardian. It must also include the name of the minor child, the name of the individual caring for them, and, if applicable, the name of the child’s primary physician.

2. Add the Minor Child’s Information

It will help assist treatment if certain information regarding the child’s medical history is included in the document. This includes:

The date of their last tetanus shot.
Any known allergies to medications or foods.
Their blood type.
Any special medication or unique pertinent information.

3. Include Additional Information

The date the consent begins and expires is essential to include in the document.

Including the insurance provider and policy number is important. The form should also indicate if the parent or guardian prefers a particular hospital.

4. Sign

At least one parent or guardian must sign the document. A witness is not usually a legal requirement, but it strengthens the document’s authenticity for medical providers.

Some medical providers may require notary acknowledgment.

Sample

Download: PDF, Word(.docx), OpenDocument

MINOR (CHILD) MEDICAL CONSENT

I/We, [PARENT(S)/GUARDIAN(S) NAME], the lawful custodial parent(s) and/or non-custodial parent(s) or legal guardian(s) of [MINOR’S NAME], born [MM/DD/YYYY], do hereby consent to any medical care and the administration of anesthesia determined by a physician to be necessary for the welfare of my child while said child is under the care of [TEMPORARY GUARDIAN’S NAME] and I am not reasonably available by telephone to give consent.

This authorization is effective from [MM/DD/YYYY] to [MM/DD/YYYY].

Parent / Legal Guardian Signature: ____________________________ Date: _____________
Print Name: ____________________________

Witness Signature: ____________________________ Date: _____________
Print Name: ____________________________

This consent form should be taken with the child to the hospital or physician’s office when the child is taken for treatment.

This additional information will assist in treatment if it can be furnished with consent but is not required.

Family Address: [FAMILY ADDRESS]

[PARENT/GUARDIAN NAME]: Telephone: [HOME PHONE #] Home [WORK PHONE #] Work
[PARENT/GUARDIAN NAME]: Telephone: [HOME PHONE #] Home [WORK PHONE #] Work

Last Tetanus: [DATE OF LAST TETANUS]

Allergies to drugs or foods: [LIST KNOWN ALLERGIES]

Special Medications, Blood Type or Pertinent Information:

[LIST KNOWN MEDICATIONS, BLOOD TYPE, IMPORTANT INFORMATION]

Child’s Physician: [PHYSICIAN NAME] Phone: [PHYSICIAN PHONE #]
Insurance: [INSURANCE COMPANY NAME] Policy # [POLICY #]
Preferred Hospital: [HOSPITAL NAME]

Sources

Ala. Code § 22-8-4

Medical Consent Form for Minor