Medical care may be unnecessarily delayed if don’t have a completed medical authorization letter sample handy in the event of a child's medical emergency.
It is a good idea to leave a copy of this type of document signed and ready to be used by your day care center, babysitter or temporary guardian in case your child needs emergency medical care.
A copy of the consent form should accompany your child to the hospital/emergency care center.
I, ____________________________________, (Name of Father/Mother) of ______________, (city) ________________, (state) the Father/Mother of _____________________________ (Name of Child), do hereby lawfully authorize ____________________________________ (Name or Names of who will be taking care of son/daughter), to make any arrangements necessary for the appropriate medical or surgical care by a licensed medical or healthcare professional of the above-named child and confer all required consents in connection therewith to the above-named ______________________________ (Name).
This medical care authorization will cease to be effective at that point in time when ________________ _____________ (Child) is permanently released from the custodial care of ____________________________ (Name) or until it is revoked by ME/US.
Full Name: _________________________________ Age: _____ Sex: _____
Date of Birth: ____/____/________
CHILD’S HEALTH INFORMATION
Health Conditions: _______________________________________ (Diabetes, Asthma...)
Allergies: _______________________________________ (Food, Medication...)
Prescription Medications: ____________________________________
Date of last Tetanus Immunization ____/____/________
CHILD’S MEDICAL CARE INFORMATION
Physitian: ______________________________ Phone: _____________________
Dentist: _______________________________ Phone: _____________________
Insurance Co.: __________________________ Policy #: ____________________
Policy Holder: _______________________________
EMERGENCY CONTACT PERSON
Name: ___________________________ Phone: _____________________
Signature of Parent Print Name
STATES: Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, D.C., Delaware, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, Wyoming.
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