Medical Consent Form for Child - Template, Sample Form

CHILD MEDICAL CONSENT AND AUTHORISATION ("Consent")

I, ________, of ________, declare that I am a parent and/or person with parental responsibility (within the meaning of the Family Law Act 1975 (Cth)) of the following child ("Child"), and that I am lawfully entitled to give this Consent.

PART A – CHILD'S INFORMATION

§1 Personal details

Full name: ________
Gender: ________
Date of birth: ________
Residential address: ________

§2 Medicare information

Medicare card number: ________
Individual reference number: ________
Expiry date: ________

§3 Private health insurance information

Health insurance provider: ________
Membership number: ________

§4 Details of treating doctor

Doctor name: ________
Medical centre: ________
Phone: ________
Email: ________

§5 Special medical needs, conditions, illnesses or allergies

________

§6 Current medication

________

§7 Immunisation details

________

PART B – AUTHORISATION

§8 Consent to treatment. I hereby consent to the following medical, dental, surgical, hospital and ambulance treatment being provided to my Child where, in the professional judgment of a registered medical or health practitioner, such treatment is necessary or advisable for the health and welfare of my Child:

________

§9 Persons authorised to act. I authorise the following person(s) to give and arrange treatment for, and to make decisions in respect of, my Child in accordance with this Consent when I am not available:

Name(s): ________
Capacity/relationship to Child: ________

§10 Emergency treatment. Where I and the authorised person(s) cannot be contacted, I consent to any registered medical or health practitioner administering such treatment (including the administration of an anaesthetic and the carrying out of a blood transfusion or surgical procedure) as that practitioner considers necessary in an emergency for the preservation of the life or health of my Child.

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§12 Best interests. I confirm that any person who acts under this Consent must at all times act in the best interests of the Child.

§13 Voluntary consent. I give this Consent voluntarily and not as a result of any payment, coercion or duress, and I consider that it is in the best interests of the Child for me to provide this Consent.

§14 Duration and revocation. This Consent takes effect on the date of execution and continues in force until the earlier of (a) the date it is revoked by me in writing; (b) the date the Child reaches 18 years of age; or (c) ________. Revocation does not affect anything lawfully done in reliance on this Consent before written notice of revocation is received.

§15 Costs. I acknowledge that I am responsible for all costs and expenses associated with any treatment provided to the Child in accordance with this Consent, including any amounts not covered by Medicare or private health insurance.

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§17 Governing law. This Consent is governed by the laws of ________, Australia, and I submit to the jurisdiction of the courts of that State or Territory.

PART C – CONTACT DETAILS

§18 If the Child is sick or injured, any relevant person must first attempt to contact me using the following details:

Name: ________
Address: ________
Phone: ________
Email: ________

§19 If I cannot be reached, the following emergency contact person may be contacted instead:

Name: ________
Relationship to Child: ________
Address: ________
Phone: ________
Email: ________

EXECUTED on ________ at ________.

Signed by the parent/guardian:

_______________________________________
________

In the presence of the following witness (being an adult who is not a party to this Consent):

_______________________________________
Witness signature

Witness name: ________

Witness title/occupation: ________

Witness address: ________

Date: ________