Medical Consent example
- 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 ____________________, ____________________, __________, __________, ____________________.
- 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:
- transportation by ambulance
h. consent to the transfusion of blood.
- 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.
- 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.
- 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.
- Any questions or concerns regarding this authorisation may be directed to me at:
Street Address: ____________________
City, Region: ____________________, __________
Home Phone: __________
Work Phone: __________
Cell Phone: __________
IN WITNESS WHEREOF, I hereunto sign my name at ____________________, __________ this 5th day of November, 2015.
For futher information, please contact:
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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