Minor Child Treatment Consent Letter

This is a written document that authorizes another adult to be able to make healthcare decisions precisely for a minor child. This letter is important as a minor is a huge responsibility, and in the unlikely event that something happens to them then others will want to treat them only if there is a consent letter from their guardian.

This is because anything can happen to the minor child while getting treated and the guardians should know this and agree to it. This form ensures that the individual authorized can get your minor child proper medical care.

Tips on writing a minor child treatment consent letter

  1. You need to identify the name as well as contact information of the parent(s) or the legal guardian(s).
  2. The child’s name, address as well as the date of birth needs to be stated for each minor.
  3. The name of the responsible adult who is authorized to make decisions for some time needs to be stated.
  4. The medical history of the child should be given. This can include the child’s health condition, any allergies, prescriptions, as well as vaccines.
  5. The name, number of the physician or pediatrician, plus dentist or orthodontist.
  6. The health insurance needs to be stated. Include the name or number of insurance, the policy or group number as well as policyholder.
  7. The letter needs to be signed by the minor child’s parent or their legal guardian.

Sample letter:

Medical Child Treatment Authorization and Consent

I, (name of guardian or parent) being the parent/guardian of (name of child) authorize (name of adult authorized) to seek, obtain plus consent to for (whatever is necessary) as the thought of as necessary by a medical or healthcare professional who is licensed. This authorization will be for the time when my child will be in the care of (name of adult authorized) and is effective until revoked by me.

Child’s Details

Full Name of Child:
Date of Birth:

Parent/Guardian’s Details

Parent’s/ Guardian’s Name:
Phone Number:
(If more than one guardian includes this)

Child’s Health Details

Health Conditions:
Prescription Medications:
Date of Last Tetanus Injection:
Child’s Medical Care plus Insurance Details
Preferred Medical Facility:
Insurance Company:
Policy or Group Number:



Minor Child Treatment Consent Letter

Format: MS Word [.doc] | Download

Simi Karton

Dr. Simi Karton currently resides in Los Angeles with her husband. This website is a voluntary work of Dr. Karton to provide people with useful health-related information with a straightforward approach.

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