Child Healthcare Consent Form - Template, Sample Form Pro · IN-law

CHILD HEALTHCARE CONSENT FORM

(Executed pursuant to the Indian Contract Act, 1872, the Guardians and Wards Act, 1890, the Hindu Minority and Guardianship Act, 1956 (where applicable), and the Digital Personal Data Protection Act, 2023)

This Child Healthcare Consent Form (the "Consent") is made and executed on this ________ at ________.

§1. DECLARATION OF PARENT/LAWFUL GUARDIAN

I, ________, son/daughter/spouse of ________, aged ________ years, holding identification (Aadhaar/Passport/Voter ID No.) ________, residing permanently at ________ (hereinafter the "Parent/Guardian"), do solemnly declare and affirm that:

1.1 I am the natural parent / lawful guardian of the minor child named below and am legally competent and entitled to grant the authority contained herein in respect of the said minor;

1.2 the particulars of the said minor child (the "Child") are as follows:

(a) Name of the Child: ________;

(b) Gender of the Child: ________;

(c) Age of the Child: ________ years;

(d) Date of Birth: ________;

(e) Place of Birth: ________.

§2. GRANT OF AUTHORITY

2.1 I do hereby authorise, empower and grant to ________, residing/having correspondence address at ________, holding identification (Aadhaar/Passport/Voter ID No.) ________ (hereinafter the "Caregiver"), the authority to obtain, arrange for, and consent to medical treatment of the Child. The Caregiver bears the following relationship with the Child: ________.

2.2 In furtherance of the foregoing, I specifically authorise the Caregiver to do, in relation to the Child, all or any of the following acts in consultation with the attending registered medical practitioner:

(a) obtain routine medical care and treatment;

(b) administer or arrange for the administration of medications as prescribed and required;

(c) provide over-the-counter medications as prudent and necessary;

(d) obtain emergency medical care and treatment;

(e) consent to hospitalisation;

(f) consent to surgery and surgical procedures;

(g) obtain dental care and treatment;

(h) grant permission for anaesthesia and surgical procedures;

(i) make decisions relating to diagnosis, examination, and laboratory tests as may be necessary for the Child; and

(j) take any other reasonable steps and decisions as may be required for the health, welfare, and well-being of the Child, in consultation with the attending physician or registered medical practitioner.

2.3 The purpose of this Consent is to confer upon the Caregiver the authority to provide for and consent to the medical treatment of the Child during such period as the Parent/Guardian is not present or available. This authority shall be effective from ________ and shall continue in force until ________, unless sooner revoked in writing by the Parent/Guardian.

§3. BEST INTERESTS AND LIMITATIONS

3.1 The Caregiver shall at all times act in the best interests of the Child and in accordance with the advice of a duly qualified and registered medical practitioner.

3.2 Nothing herein shall be construed so as to authorise any act prohibited by law or to derogate from the rights of the Parent/Guardian, which rights are hereby reserved save to the extent expressly delegated under §2.

3.3 This Consent does not create any agency for the purpose of incurring financial liability beyond what is reasonably necessary for the medical welfare of the Child, save as may be expressly agreed between the parties.

§4. HEALTH CONDITION OF THE CHILD

4.1 The Child has the following special conditions/allergies:

________

4.2 The Child is presently taking the following medications:

________

4.3 The last Tetanus injection/Booster shot was administered to the Child on:

________

4.4 The Child's blood group is: ________.

4.5 For routine check-up and consultation, the Caregiver may prefer the following physician:

________

§5. INSURANCE DETAILS

Name of insurance company: ________

Policy No.: ________

Name of policy holder: ________

§6. CONTACT DETAILS OF THE PARENT/GUARDIAN

In case of emergency, the Parent/Guardian may be contacted at the following details:

Name: ________ (Parent/Guardian)

Address: ________

Phone No.: ________

Email: ________

§7. EMERGENCY CONTACT DETAILS

In case of emergency, where the Parent/Guardian is not available, the Caregiver or the concerned person may contact the following:

Name: ________

Relationship to Child: ________

Phone: ________

Email: ________

§8. DATA PROTECTION

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8.2 Such data shall be processed only to the extent necessary for the said purpose and the consent granted hereunder may be withdrawn by the Parent/Guardian at any time by written notice, without prejudice to lawful processing carried out prior to such withdrawal.

§9. INDEMNITY

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§10. REVOCATION

10.1 This Consent is revocable at any time by the Parent/Guardian by written notice delivered to the Caregiver, and shall in any event stand terminated upon the expiry of the period stated in §2.3 or upon the Child attaining the age of majority, whichever is earlier.

§11. GOVERNING LAW AND JURISDICTION

11.1 This Consent shall be governed by and construed in accordance with the laws of India.

11.2 The courts at ________ shall have exclusive jurisdiction in respect of any matter arising out of or in connection with this Consent.

§12. DECLARATION

I declare that I have read and understood the contents of this Consent, that the same have been executed by me out of my own free will and without any coercion, undue influence, fraud, or misrepresentation, and that the particulars stated herein are true and correct to the best of my knowledge and belief.

_______________________

Signature

________

(Parent/Guardian)

Date: ________

WITNESSES

1. Signature: _______________________

Name: ________

Address: ________

2. Signature: _______________________

Name: ________

Address: ________