Grandparent Medical Consent Form

Information you will need

• What's the child's name?
• What's the grandparent's name?
• What's the child's date of birth?
• On what date does the authorization begin?
• On what date does the authorization end?
• What's the child's address?
• What's the physician's phone number?
• What's the name of the child's physician?
• Who's the child's health insurance provider?
• What's the child's insurance policy number?
• What other details should be mentioned?
• What's the child's blood type?
• NOTARY ONLY: What's the state?
• NOTARY ONLY: What's the county?
• NOTARY ONLY: What's the acknowledgment date?
• NOTARY ONLY: What's your name?
• NOTARY ONLY: Which state laws will govern this acknowledgment?
• NOTARY ONLY: What's your printed name?
• NOTARY ONLY: On what date does your commission expire?
• What are the child's allergies?
• What medications does the child take?
• What's the parent's or guardian's printed name?
• What's the other parent's or guardian's printed name?
• What are the names of the child's parents or guardians?

…and 4 more fields in the PDF.

The form includes 3 signature lines, a notary acknowledgment, a witness section.