Free Permission Letter to Take Child to Doctor [Sample]

A permission letter to take a child to the doctor permits a parent or legal guardian to delegate all health-care choices for their child to a temporary caregiver. 

Once created, the temporary caregiver must present this authorization letter whenever the child is treated or diagnosed at a medical facility. 

Use this sample permission letter to take your child to the doctor as a guide for writing your own letter.

Permission Letter To Take Child To Doctor Sample

Your Name
Your Address
City, State, Zip Code


RE: Permission Letter

To Name of Doctor:

I, Name of Legal Guardian, am the lawful guardian of the female child named below. I give permission and consent to Name, Address and Phone Number of Temporary Caregiver to authorize medical treatment for Full Name of Child and date of birth.

This permission is granted from DATE and will expire on DATE.

Signature          DATE
Your Name

Signature of Witness or Notary (if required by the state) DATE
Printed Name of Witness

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