Grandparents’ Medical Consent Form – Minor (Child)Grandparents’ Medical Consent Form – Minor (Child)
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GRANDPARENT MEDICAL CONSENT (FOR A MINOR)
I, ______________________, the parent or legal guardian of ______________________,
residing at ______________________________________________________ [Address]
born on the ___ day of _______________________, 20___ do hereby consent and allow
______________________ [Grandparent] to handle any type of medical care for my child
including but not limited to the administration of anesthesia determined by a physician, surgery,
and any other care recommended or deemed as necessary for the welfare of my child.

This authorization is effective from on this ___ day of _______________________, 20___ and
expires on the ___ day of _______________________, 20___

_____________________________________

___________

_____________________

Signature of Parent or Legal Guardian

Date

Print Name

_____________________________________

___________

_____________________

Signature of Witness

Date

Print Name

This consent form should be taken with the child to t