Minor Child Treatment Consent Letter

This is a written document that authorizes another adult to be able to make healthcare decisions specifically for a minor child. This letter is important as a minor is a huge responsibility, and if something happens to them, 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 the contact information of the parent(s) or the legal guardian(s).
  2. The child’s name, address, and date of birth must be stated for each minor.
  3. The name of the responsible adult 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, and vaccines.
  5. The name and number of the physician or pediatrician, plus the 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 the policyholder.
  7. The letter needs to be signed by the minor child’s parent or their legal guardian.

Sample letters


I am writing to officially provide consent for the treatment of my two-year-old child, John Doe, at XYZ Hospital. He will undergo surgery for tonsillitis as recommended by medical experts.

I understand there might be complications during the procedure. The doctors have provided me with complete information about the procedure, its potential risks, and the possible side effects of post-surgery medications. I provide my permission to go ahead with the procedure in the hope of the long-term well-being of my child.

I expect the doctors to do their best to minimize the risks and side effects involved. I trust in the capability of the medical staff at XYZ and request that they treat my child with the utmost care.


I am writing this letter as the guardian of (Name of Child), age seven years, to provide my consent to ABC Hospital to conduct her chemotherapy on (date).

I understand the challenges and side-effects of the procedure. However, as her caretaker, I give her permission to administer chemotherapy medication to treat her leukemia. It is crucial for her well-being.

I also understand that her medication dose might need to be increased as per requirements This could lead to worse side effects. With all this knowledge and understanding, I provide my consent for the adjustment of the dose according to what the doctors consider best.

Thank you for providing the treatment, and I hope the planned chemotherapy sessions will be successful.


I am writing this consent letter for the treatment of my four-year-old son at XYZ Hospital. I have signed the consent form and completed all the required formalities for the treatment to begin as soon as possible.

Please let me know if there are any further requirements. Thank you for your assistance.


Medical Child Treatment Authorization and Consent

I, (name of guardian or parent), being the parent or guardian of (name of child), authorize (name of adult authorized) to seek, obtain, and consent to (whatever is necessary) as thought 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 or 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

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