Permission Letter to Take Child to Doctor [Free Sample]

Below is a permission letter to take child to doctor. It should be written in formal business-letter style and notarized or witnessed if required. 

The original can be given to the temporary caregiver, and a copy should be kept by the legal guardian.

Permission Letter To Take Child To Doctor [free 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 Of Legal Guardian DATE
Printed Name of Legal Guardian

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