GRANDPARENT MEDICAL CONSENT (FOR A MINOR)
I, ______________________, the parent or legal guardian of ______________________,
residing at ______________________________________________________ [Address]
born on the ___ day of _______________________, 20___ do hereby consent and allow
______________________ [Grandparent] to handle any type of medical care for my child
including but not limited to the administration of anesthesia determined by a physician, surgery,
and any other care recommended or deemed as necessary for the welfare of my child.
This authorization is effective from on this ___ day of _______________________, 20___ and
expires on the ___ day of _______________________, 20___
_____________________________________ ___________ _____________________
Signature of Parent or Legal Guardian Date Print Name
_____________________________________ ___________ _____________________
Signature of Witness 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 the consent but is not required.
Father’s Telephone: _____________________ Mother’s Telephone: _____________________
Allergies to drugs or foods: ______________________________________________________
Special Medications, Blood Type or Pertinent Information: ______________________________
____________________________________________________________________________
Child's Physician: __________________________ Phone: ________________
Insurance: ________________________________ Policy # ________________
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