Medical Consent example

  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.








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

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