Travel & consent letters
Consent for Medical Treatment of a Minor Child
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CONSENT FOR MEDICAL TREATMENT OF A MINOR CHILD
I, ______, of ______, in the Province of Ontario, MAKE OATH AND SAY (or AFFIRM) 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 (if available):
Known allergies, conditions, or medications (if any):From ______ to ______, I authorize ______ (______) to consent on my behalf to medical, dental, and emergency treatment for the Child where I cannot be reached.
Limits or instructions on this authorization (if any):
I make this statement to confirm the caregiver’s authority to act in the best interests of the Child.
Signed and sworn (or affirmed/declared) before me by videoconference in Ottawa, Ontario, while the Affiant(s)/Declarant(s) were located in ______________________, on ______________________, pursuant to O. Reg. 431/20, and Electronic Commerce Act, 2000.
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