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CONSENT FOR MEDICAL TREATMENT OF A MINOR CHILD
I, ______, of ______, in the Province of Ontario, MAKE OATH AND SAY that:
I am the ______ of ______, born on ______ (the "Child"), and I have lawful authority to consent to the Child’s health care.
The Child’s Ontario health card number is . Known allergies, conditions, or medications are: .
From ______ to ______, I authorize ______ (______) to consent on my behalf to medical, dental, and emergency treatment for the Child where I cannot be reached.
This authorization is subject to the following limits or instructions: .
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