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Caregiver Consent Form Template

Streamline consent collection with a customizable caregiver form

Gathering informed consent can feel overwhelming, especially when dealing with sensitive situations. This caregiver consent form template is designed to simplify the process for healthcare professionals, ensuring you collect the necessary approvals from parents seamlessly. By using this template, you can enhance compliance, protect patient privacy with HIPAA options, reduce administrative burden, and speed up your consent collection process. Experience peace of mind while focusing on what truly matters-providing care. Feel free to try the live template now!

Use this Template (FREE) Live Preview
Child full name
Child date of birth
Parent/guardian full name
Primary phone number
Email address
Caregiver full name
Caregiver phone number
Caregiver relationship to the child
Grandparent
Aunt/Uncle
Sibling (18+)
Family friend
Nanny/Babysitter
Teacher/Coach
Neighbor
Other
Please Specify:
Consent start date
Consent end date
Activities authorized (select all that apply)
Authorize caregiver to pick up/drop off the child from school or activities
Yes
No
I authorize the caregiver to seek medical or dental care for the child if necessary
Yes
No
Medical conditions, allergies, or special needs
Health insurance provider
Policy or member ID
Emergency contact full name
Emergency contact phone number
Permission to administer basic over-the-counter medications according to label directions
Yes
No
I am the child's parent or legal guardian with authority to grant this consent
Yes
No
I understand this consent remains in effect for the dates indicated unless I revoke it in writing
Yes
No
I consent to the use of electronic records and my typed name as my signature
Yes
No
Parent/guardian typed full name (signature)
Date of signature
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paper art illustration features caregiver consent form template with decorative elements and text highlighting key sections

When to use this form

Use this authorization when a non-parent or support person needs clear, time-limited permission to make care decisions. It helps families, schools, clinics, and pharmacies act without delay. Examples: a grandparent takes a child to urgent care, an adult child manages appointments for an elder, or a nanny joins a virtual visit. List the caregiver, scope of decisions, dates, and contacts so staff can verify authority and share information. For in-clinic treatment policies, align with the Consent to treat form. If remote visits are likely, reference the Telehealth consent form. For medication pick-up or approval, include clear instructions in this form so pharmacies and school nurses know what is allowed.

Must Ask Caregiver Consent Questions

  1. What is your relationship to the patient, and what are the start and end dates of your authority?

    This proves you have standing and sets a clear window for decision-making. It prevents disputes at check-in and reduces calls to verify consent.

  2. What medical decisions are you authorized to make, and are there any limits or exclusions?

    Detailing scope (routine care, emergencies, information sharing) helps staff act confidently. If vaccines are excluded, pair this with a signed Vaccine refusal form to avoid confusion.

  3. Are you allowed to approve prescriptions, refills, and over-the-counter medications?

    Pharmacies and schools rely on this to dispense or administer medication safely. If your workflow needs extra detail, attach a Prescription authorization form so pharmacists have written proof.

  4. Who are the primary contacts and preferred facility if an emergency occurs?

    Listing guardian phone numbers and a preferred clinic or hospital speeds triage. It also gives staff a backup contact if a decision exceeds your authority.

  5. Do you authorize telehealth visits and release of records needed for remote care?

    Stating this upfront prevents delays when a provider schedules a virtual appointment. It also guides staff on what they may share during a video visit.

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