Designation of Another Person to Consent for Medical Care

Designation of Another Person to Consent for Medical Care

It is best that children are brought for medical treatment by a parent or legal guardian. However, there may be times when someone other than you takes care of your child. That person may be a baby-sitter, teacher or family member. If your child must be seen at a Nationwide Children's Hospital at these times, we need a signed consent form to provide medical care.

This consent form allows the person you choose to seek medical treatment and sign consent for your child when you are unable to come with the child.  The person you name must be 18 years of age or older.

How to Use this Consent Form

1. Ask for or make several copies of this form.
2. Complete all the information on pages 2 and 3 of this form. Use a separate form for each child.
3. Sign and date the form and have an adult witness your signature. The person who will accompany your child can be the witness of your signature.
4. Give the completed form to the person you have chosen. Have the person bring the consent form and shot records when he or she brings your child to the Nationwide Children's Hospital.
5. Be sure to tell the person who comes with your child to get the doctor's and nurse's instructions in writing before leaving the Nationwide Children’s Hospital. If you have questions about the instructions, be sure to call the doctor or nurse.
6. This Consent for Medical Care is good for one year.  It is kept in your child’s chart. A new form must be completed and signed every year. There needs to be a different form for each person bringing the child.

Medical Information

List the following information about your child:

• Name of Child:__________________________________________________________

                       Last Name                      First Name                        MI

• Birth Date:  ___________________________________________________________
• Allergies:______________________________________________________

                   ____________________________________________________________

• Allergies to medicines:________________________________________________

                     _______________________________________________________________
                     _______________________________________________________________

• Hospitalizations at Nationwide Children's Hospital and other hospitals (list dates and reasons for admissions):______________________________________________

                 _______________________________________________________________

                 _______________________________________________________________

• Medication(s) child is taking:____________________________________________
• Immunizations (shots) child has had. Please bring shot records with the child._________________________________________________________________
• Other information:______________________________________________________

                          _______________________________________________________________

                          _______________________________________________________________   

Designation of Another Person to Consent for Medical Care (PDF)

HH-36 11/11 Copyright 2011, Nationwide Children's Hospital