1. I, ____________________ of ____________________, ____________________, __________, __________, ____________________ make oath and say that I am the lawful guardian of the child listed below and there are no court orders now in effect that would prohibit me from conferring the power to consent upon another person.
    

   Information of Child

   ____________________, male, born _________________, 201___ at ____________________ and residing at ____________________, ____________________, __________, __________, ____________________.
   
    

2. I hereby authorise and appoint ____________________ of ____________________, ____________________, __________ __________ as my agent. My agent may consent to my child's  medical examination or treatment. Such treatment may include but is not limited to the following:
   1. transportation by ambulance
   2. examination
   3. x-rays
   4. diagnoses
   5. hospitalisation
   6. anaesthesia
   7. medication

      h. consent to the transfusion of blood.

3. The purpose of this instrument is to give ____________________ the power and authority to consent to medical treatment for my child and this power and authority will be effective as of the 5th day of November, 2015.
4. I give this consent freely and knowingly in order to provide for the child and not as a result of pressure, threats or payments by any person or agency.
5. This consent will remain in effect until it is revoked by notifying my child's medical, mental health care and insurance providers, in writing, and the agent named above that I wish to revoke it.
6. Any questions or concerns regarding this authorisation may be directed to me at:
    

   Name: ____________________ Street Address: ____________________ City, Region: ____________________, __________ Postcode: __________ Country: ____________________ Home Phone: __________ Work Phone: __________ Cell Phone: __________ Email: ____________________

    

IN WITNESS WHEREOF, I hereunto sign my name at ____________________, __________ this 5th day of November, 2015.

 

Witness		Witness
Print Name		Print Name

 

For futher information, please contact:

Louwrens Koen Attorneys

Loftus Versveld Northern Pavillion (Gate12), 2nd Floor Office 4, 416 Kirkness Street, Arcadia, Pretoria

Tel: 087 0010 733

Cell: 084 316 3765

This email address is being protected from spambots. You need JavaScript enabled to view it.

Order Now

Full permission to travel letter, notarisation and legalisation service.

Permission for minor children to travel - Signed before Notary Public and Notarised