Grandparents’ Medical Consent Form - Minor (Child)

The form on the next page can be photocopied as often as needed.  Or, you may want to devise your own form using it as a model.

It is not meant to take the place of sound legal advice. You may want to consult with your attorney to be certain it is appropriate for your family’s particular needs.

Be sure to instruct your caregivers:

·        On the need for and use of the consent forms.

·        That the consent forms are in or by emergency phone numbers.

·        To give the Caregiver Consent Form to the Emergency Medical Service or to take it to the emergency room so all necessary information for prompt and appropriate care will be available in your absence.

·        To become familiar with the name and group number of your insurance carrier, a critical concern to hospitals or other emergency centers.

Keep a photocopy of your Insurance ID Card with the form.

 

 

 

 

 

 

 

 

 

 

 

 

 

Consent for Medical and/or Emergency Treatment  

I, ___________________________________________, hereby voluntarily consent to the rendering of such care, including diagnostic procedures, surgical and medical treatment, and blood transfusions, by medical doctors, hospitals or their authorized designees, as may in their professional judgement be necessary to provide for the medical, surgical or emergency care of my

 

__________________________________     ____________________________________.

    (Relationship – “Grandmother” or “Grandfather”)                     (hereafter “dependent”) – Full Name

I further give my consent to _____________________________________________________________,

                                                                                                     (hereafter “caregiver”) – Full Name

 

who will be caring for my dependent for the period ________________ through _________________, to arrange for routine or emergency medical and/or dental care and treatment necessary to preserve the health of my dependent.  In the event that my dependent is injured or ill while under the care of the caregiver, I hereby give permission to the caregiver to provide first aid for said dependent and to take the appropriate measures, including contacting the Emergency Medical Service (EMS) system and arranging for transportation to the nearest emergency medical facility.

In making medical decisions on my behalf for the benefit of my dependent, I direct that the caregiver attempt to contact me.  However, if medical care becomes essential, I give permission to the caregiver to make such decisions regarding such treatment as deemed appropriate by the medical doctor, hospital or their authorized designee.  In furtherance of any treatment decisions to be made by the caregiver on my behalf for the benefit of my dependent, I authorize the caregiver to request, obtain, review and inspect any and all information bearing upon my dependent’s health and relevant to any such decisions to be made respecting such treatment.

I acknowledge that no guarantees have been made to me as to the effect of such examinations or treatment on the condition of my dependent and that I am responsible for all reasonable charges in connection with the care and treatment rendered to my dependent during this period.

                                                                                 

____________________________________    ____________________________________

Signature of Legal Guardian                                                   Primary Care Physician’s Name

____________________________________    ____________________________________

Signature of Witness                                                                 Primary Care Physician’s Address

____________________________________    ____________________________________

Witness’s Name                                                             Primary Care Physician’s Address 2

____________________________________    ____________________________________

Witness’s Address                                                       Primary Care Physician’s Phone

____________________________________     

Witness’s Address 2                                                                             

____________________________________    ____________________________________

Witness’s Phone                                                            Current Medications

____________________________________    ____________________________________

Health Insurance Carrier                                              

____________________________________    ____________________________________

Health Insurance Policy # and Group #                                 

____________________________________    ____________________________________

Allergies                                                                        Date of Last Tetanus Booster   

____________________________________    ____________________________________

Allergies (cont’d)                                                           Medications Dependent is taking