Preview Medical Consent Form For Grandparents

Consent to Treat

(For NON-PARENT caregivers of minor children when a parent is not present)

Child’s name Date of Birth

When I/we, the undersigned parent(s) or legal guardian(s) of the child listed above, are not present,

I/we authorize: who is to the child

Name of adult who is the NON-PARENT caregiver (grandparent, aunt, babysitter, etc.)

whom you are authorizing to give consent to treat

and a caregiver of this child, to consent to any X-ray examination, anesthetic, medical or surgical

diagnosis, immunizations, injections or treatment; and/or hospital care to be provided to said child,

when such services are recommended and supervised by Cottonwood Pediatrics. I/We authorize

Cottonwood Pediatrics to call in, at their discretion, any necessary consultants.

I understand that, despite this consent, Cottonwood Pediatrics, in its sole discretion, may decide not to

act on this consent, and instead require my presence during my child’s treatment or care.

I also understand that I am financially responsible for any co-pays and charges not covered by my

insurance which are incurred as a result of this consent for treatment and care.

Unless it is revoked sooner in writing, this consent remains in effect until my child is

 18 years old  until the _____ of ________________, 20 ___.

Father’s signature AND/OR Mother’s signature

Date OR Legal Guardian’s signature

Parent / guardian’s

home address: Phone:

Parent / guardian’s

employment: Phone:

Other phone number(s) at which parent or guardian can be reached:

Child’s known allergies:

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