Minor Child Medical Consent Form

Information you will need

• What’s the name of the parent /guardian ?
• What’s the minor child's name?
• What's the minor child's birthday?
• Who is taking care of the minor child?
• When does this authorization begin?
• When does this authorization expire?
• What's the parent/guardian's full name?
• What's the second parent/guardian's full name? (if applicable)
• What's the name of the witness? (if applicable)
• What's the family's home address?
• When was the minor child's last tetanus shot?
• What are the minor child's allergies?
• What other pertinent information should be known about the minor child?
• What's the name of the minor child's physician?
• What's the physician's phone number?
• What's the insurance company?
• What's the policy number?
• What's the preferred hospital?
• What's the parent/guardian's phone number?
• What's the second parent/guardian's phone number? (if applicable)
• What's the parent/guardian's work phone number?
• What's the second parent/guardian's work phone number? (if applicable)

The form includes 3 signature lines, a witness section.