Consent for Medical Treatment of a Minor Child

CONSENT FOR MEDICAL TREATMENT OF A MINOR CHILD

I, ______, of ______, in the Province of Ontario, MAKE OATH AND SAY that:

1. I am the ______ of ______, born on ______ (the "Child"), and I have lawful authority to consent to the Child’s health care.

2. The Child’s Ontario health card number is ______. Known allergies, conditions, or medications are: ______.

3. From ______ to ______, I authorize ______ (______) to consent on my behalf to medical, dental, and emergency treatment for the Child where I cannot be reached.

4. This authorization is subject to the following limits or instructions: ______.

5. I make this statement to confirm the caregiver’s authority to act in the best interests of the Child.

SWORN / AFFIRMED before me at the ______________________ of ______________________, in the Province of Ontario, this ______ day of ______________, 20______.

_______________________________ _______________________________

A Commissioner for taking Affidavits Signature of Deponent