20 answers

Wording for Treatment Consent?

Hey ladies! My husband and I are finally taking a vacation with another couple this weekend. We are going to St. Louis and will be going without kiddos. My parents are going to stay with my daughter at our house and we will be gone three days. My mom and I were discussing the plans, and she wanted me to write something up saying she and my dad have consent to treat my daughter just in case anything happens. I'm glad she thought of that because I sure haven't! We are not anticipating any problems, but better safe than sorry! I am planning on making a cop of my insurance card, but how would you word the consent thing? I was thinking something along the lines of......_________ (parents names) have my permission to treat ________ (daughter's name)........and then I'm stuck! Anyone have any ideas? Thanks!

1 mom found this helpful

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I do this everytime I leave my kids with someone and have parents do the same when they leave their kids with me.

I, ____________________ (your name), give permission for _____________________ (care provider's names) to seek, obtain, and authorize medical treatment for my children.__________________ (child's name) and _________________ (child's name) in my absense.


Insurance information:______________________(Carrier and I.D.#)

My social security number is_________________________

Primary care physician is____________________________

Then list any allergies or current medication for each child.
If there are none, indicate that on your letter.

Leave an emergency contact number where you can be reached.

Signature and printed name.

Then, you're good to go.

If you have a copy of your insurance card, include it with the letter.

For next time, you can always change the date or the name of the person your kids will be with. But there's never been any problem with this format.

You likely won't need it, but it's better to have it on hand so you can go and know the bases are covered.

Best wishes!

2 moms found this helpful

Updated and added: I just wanted to throw this out there since there have been a few responses talking about the effectiveness of these consent forms. I realize things can change and rules may differ, etc. but last spring '09 a neighbor was watching her niece and nephew while their parents were on a cruise. She called 911 when the little girl fell out of a tree. The computer printed form similar to the ones people have recommended, signed and dated by both parents, was enough consent to get the girl an ambulance ride, emergency admission, x-rays and medical care.

I would add.... some wording along the lines of 'In the event that we can't be reached..." That way you are saying if you can't be contacted first then whoever you appoint then has your autho to decide medical treatment. I would also add my childs height and weight to this info. This is good for whomever is caring for your children to have. If you have ever had to call 911, depending on the emergency this can be important info.

2 moms found this helpful


We, WIFE AND HUSBAND DOE, parents of minor child, JANE MARIE DOE -- DOB 1/1/2010, give permission to, JANE AND/OR JOHN SMITH (Maternal grandparents), to seek, obtain and authorize any emergency, medical, surgical or dental treatment or procedure including but not limited to tests and anesthesia for our child in the event that we are unavailable for immediate contact to give our parental authorization or if time is a factor in her immediate care and treatment.

Authorization effective Monday, July 5, 2010 to Friday, July 9, 2010.

JANE MARIE is not currently on any medications and has no known allergies to our knowledge at this time.


Contact in the following order: ( I put this on mine because if something were to happen I want to be the one they notify first, personal preference)

Home: ###-###-####
Cell: ###-###-#### Wife
Cell: ###-###-#### Husband
Work: ###-###-#### Husband

___________________ STACEY DOE / dated
___________________ HUSBAND DOE / dated

I also don't put my pediatrician contact info because it's just a personal preference.

I attach a copy of the insurance card.

1 mom found this helpful

Mine looks just like Shane's... except that when it's family I list the relationship and add our preferred hospital.

1 mom found this helpful

I got a program called Family Lawyer by Broderbund. With it you just plug in all of the information and then print it out. It can make simple wills, business contracts and lots of different documents. I wasn't an expensive program and I have used it many times in the past 6 or so years. When ever my grands come to visit their mom signs it - and when we go out of town I use it for my little son's caregiver. I also include their insurance cards. I have never had to use one (fortunately) but they look very professional and they are really quick.

You might contact your kids doctor's office and also the hospital (and school if they are in school) and get the forms there. They might require a notary. We did that when we went out of town for a few days.

I didn't read the other replies but I think you have to have a power of attorney (if that is what it's called) for your parents in order for any doctor to see her because any person could take a child and write a letter and sign your name (IMO). Not sure just a letter would work. However, my dad was military so that is why they always had a power of attorney for us when someone took care of us while he and mom were away. May be different in the civilian world.

I have done this before. Each time I asked either our doctor or our attorney. They were very helpful.

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