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Canadian Child Medical Consent

General Info
Parents/Legal Guardians
Child Details
Caregiver
Final Step
Print/Download

Caregiver

Number of caregivers:

One Two

Caregiver Details

First Caregiver Details

Name:

Address:

Second Caregiver Details

Name:

Same address as first caregiver?

Yes No

Address:

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Powers of Caregiver

The caregiver can consent to the following treatments:

Blood transfusion

Surgery

Mental

Dental

Developmental

Allow caregivers access to any medical/insurance records related to your child's health care treatment?

Yes No

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