Wording for Treatment Consent?

Updated on June 15, 2010
R.D. asks from Haysville, KS
20 answers

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!

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answers from Oklahoma City on

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.

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answers from Redding on

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!

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answers from Oklahoma City on


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


answers from Seattle on

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

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answers from Springfield on

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.



answers from Houston on

I would google medical release forms. Or you could go by whatever your child's school or daycare had you sign.



answers from Kansas City on

I always listed the kids names, Date of Birth and allergies across the top.
Then their doctor's name, address and phone number.
Then something along the lines of. . .
'The above named children will be in the care of _______ from ___(date) through ____ (date).
_________(list the caregivers names again) may act on my/our behalf in authorizing unexpected medical, dental, surgical care and hospitalization during the time ______ (kids names) are in their care.

Parent/s printed name
parent/s signature

Our names
addresses and all possible phone numbers

I usually tried to have it notarized and also left either a copy of the insurance card or a card itself.

Good Luck and have fun!



answers from Columbus on

Call your pediatrician's office, they may have a form, same with the children's hospital in your area, they can tell you exactly what they need from you in case of emergency. That should cover all your bases. They do need some kind of consent to treat, we just write something up like what you have planed, and list all the answers the typical questions that they ask at an urgent appointment-allergies, meds, etc. That was all that was required by our children's hospital. You just want to be sure that they have what is required in your area.

Have fun!



answers from St. Louis on

Call the emergency room where your child is most likely to be taken sometimes they have a form that can be used. I also happen to have a Girl Scout Health history and a sports physical that I attach which lists all current info. Good luck



answers from Houston on

My MOL asked me to do the same thing recently and that's about all I included. Just be sure to list any allergies and if you know it, blood types. I also left her with the phone number and directions to the pediatricians office, a list of approved meds and doses (tylenol, benedryl, etc) and the name/phone number of a babysitter in case things got overwhelming and she needed help. I also wrote out my daughters general schedule (bed times, meal times, nap times and anyother info that might be useful). She greatly appreciated having the info handy and luckily didn't need any of it!

Enjoy your trip and try not to worry! It's very important for you and your husband to have time together as a couple.



answers from Kansas City on

Due to my absence from June 16 through June 19, 2010, my parents, John and Jane Doe, will be responsible for the care of my daughter, Susie Whomever. They have permission to make decisions regarding emergency medical treatment until my return on June 20, 2010.

Mary Smith
June 15, 2010



answers from St. Louis on

Here is what I use for our trips, along with copies of the insurance card as you stated:

I, {your name}, authorize my {relation i.e. mother, father, sister}, {relations name}, to seek medical attention for my daughter/son {or children}, {child/childrens name(s)}, during my absence {date of absence}.

Your Name

State of { }, County of { }. On this {date}th day of {month} in the year 20??, before me, {Notary’s Name}, a Notary Public in and for said state, personally appeared {your name}, known to me to be the person who executed the above letter of authorization and acknowledged to me that she executed the same for the purposes therein stated.

My Commission Expires:

{Notary’s Name} (Notary Public)



answers from Joplin on

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



answers from Dallas on

I have this page bookmarked. We re-typed it and used it when I was in the hospital having baby #2. It seemed to cover everything and it gave the grandparents all the contact information right there on one sheet. Our child doesn't have allergies or medical issues, but I imagine they could be added as needed.




answers from Kansas City on

Consent treatments are not as effective as people think. Do to HIPPA laws, some hospitals may not accept them.. Hospitals are required to stabilize a child.

Contact the hospital that she would be treated at in case of an emergency to ask what they require. Also, do a form with her regular doctor stating your mom and dad have permission to consent. Ask for a copy to give to your parents.



answers from Wichita on

Your doctor's office should have a form you can use.



answers from Detroit on

Child's name -----------------------------------
Date of Birth-------------------------------
Home phone number---------------------------
Home address---------------------------------------
city, state, Zip code-----------------------------
Parental Contact-------------------------------
Caregiver Info.--------------------------------------

Family Physicial Information----------------------------
List of Known allergies
Current Medications

The above name caregiver shall be authorized to consent for all medical and/or surgical treatment and/or other medical proscedures (including administration of anesthesa, blood transfusions, diagnostic tests, etc) for the above named child, which may be required during my absense. If circumstances permit, I would like to have our doctor consult in connection with such treatment.

Please attempt to contact me at the following telephone number
This authorization shall be effective until. (Select dates)




answers from Dallas on

I just had to do this when my kiddos went on vacation with their aunts and cousins ! I just typed up a sheet of paper, dated it, and stated "The following people have our permission to obtain medical and/or dental care for ________________ and ____________." The I listed the adults names. Then I listed out our contact information - including phone numbers and address. Then my husband and I both signed it. I then attached copies of the boys insurance cards. I also did a sheet for each child listing what medication they take and dosages, any allergies, and any medical history including previous surgeries. This may have been overkill but I tend to think of the worst scenario and what medical professionals tend to ask (on any medications, any previous surgeries and any complications, any allergies, etc). oh and with each boy I listed their doctor and dentist and their contact information.



answers from Lawrence on

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.


answers from St. Louis on

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.

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