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Child Medical Consent Form

Use our free Child Medical Consent Form to collect a parent/legal guardian’s consent and approval and provide medical authorities with the ability to perform medical treatments on a child when needed. This template includes details about the form’s purpose as well as policies regarding consent, withdrawal, and financial information. The parent/legal guardian can indicate their understanding and acknowledgement and grant the medical providers permission to treat their child by signing the form at the bottom. If the parent/legal guardian of the child cannot sign the form on their child’s behalf, there is an additional section for them to include an alternate contact. This version of our medical consent form is intended for children and pediatric patients. We have a template for the adult version of a medical consent form available as well.

We also included an internal section for staff to add notes and indicate once they’ve added the consent form to their medical file. Using workflow statuses and the Entries page, staff members can easily monitor each entry’s progress and status.

All data collected can be made HIPAA compliant with our Enterprise plan after signing our Business Associates Agreement (BAA). Additionally, our data encryption capabilities can help ensure your data is secure both at rest and in transit.

Customize and adjust this template by adding, removing, and editing fields as you see fit. You can create an organization theme and ensure that your branding remains consistent throughout all your forms. It’s also easy to directly embed this form onto your practice’s website, if needed, as well.

Child Medical Consent Form

Use our child medical consent form to collect a parent/legal guardian's consent and approval prior to any medical treatments for their child.



  • Patient
  • Internal Staff


  • Incomplete
  • Submitted
  • Processed