I hereby undertake that I Mr. [NAME] s/o Mr. [NAME] is the lawful guardian of Mr. ABC, who is currently under medical consideration in your hospital. My child has to undergo major brain surgery and unfortunately, I am out of the station. Hence, I cannot sign the relevant documents needed by the hospital. Therefore, I with my full consent name Mr. JKL (grandfather of the child) to make medical decisions for my child on my behalf. The terms of the consent are the following:
- I am giving the power and authority to Mr. [NAME] to give consent for the medical treatment of my child.
- This consent is valid with effect from Tuesday 5th October 20XX to 20th November 20XX or else informed otherwise.
- Mr. [X] can give consent for all sorts of emergencies and medical treatment in the consented period.
- I give complete authority to MR. [NAME] to access all the medical records of my child.
I undertake that I have given this consent freely and I am not bribed or forced to give it. Now that I have appointed Mr. [NAME] as my child’s guardian to give consent for a medical checkup, kindly start the treatment of my child that we may deal with the surgery in time. If you have any further questions kindly let me know. I have attached a copy of the signed agreement for your convenience. Looking forward to hearing from you soon.
I hope all is well with you. I am the mother of Mr. [NAME] who is currently in need of medical attention. I received a call from your hospital yesterday. The nurse informed me that my child Mr. [NAME] is diagnosed with a cyst on his optic nerve, and it needs to be removed immediately or else my child can lose his eyesight. Moreover, she told me the process of removing the cyst will be nasal and anesthesia, blood transfusion, and some other medical procedures are to be used for which my written signed consent is required.
Unfortunately, I cannot come to the hospital because of some business emergency. Therefore, I nominate Ms. ABC (teacher of my child) to be the temporary guardian of my child for medical purposes. The terms of this consent are the following:
- Ms. [NAME] can have access to all the medical records of my child, but the process of bill payment and documents of insurance will be kept hidden from her.
- Ms. [NAME] will be able to give medical consent for medical treatment of my child with effect from Tuesday 5th October 20XX till 31st October 20XX or else I revoke the agreement.
- I am giving this authority to Ms. [NAME] willingly. She can give consent for anesthesia, blood transfusions and other medical procedures needed for the surgery.
- She can also give consent for routine medical checkups pre or post-surgery within the mentioned period.
Kindly start the treatment of my child immediately so, we find a cure for the problem. If you have any further questions, please do not hesitate to contact me. You may contact me on my number [X] or else you can drop an email at [X]. Thanking you in anticipation.