Consent for Medical Treatment of Minor - Michigan

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Michigan · Fillable PDF · Free

A parent uses this form to let a babysitter, relative, coach, or other adult consent to medical or dental care for a child while the parent is away. A parent uses this form to let a babysitter, relative, coach, or other adult consent to medical or dental care for a child while the parent is away.

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Who this form is for

A parent uses this form to let a babysitter, relative, coach, or other adult consent to medical or dental care for a child while the parent is away.

What you'll need

Read the packet and check the receiving agency's required form.
Gather the names, dates and supporting records requested in the document.
Review the packet's signing, identification and witness instructions.

How to complete it

Fill in the child and adults (Page 1) Include the parents, the person giving consent, and the adult who may consent to treatment.
Describe the treatment (Page 1) Authorize all advisable treatment or only specific treatment, and set the dates.
Sign in front of a notary Do not sign ahead of time. Bring a current, government-issued photo ID for each person signing.
Give the original to the caregiver and keep a copy. Include a copy of the child’s insurance card.
For a longer absence, consider a Michigan Parental Power of Attorney. We have a free form.

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