Good Medical Consent Letter for Grandparents [Samples]

Learn how to write a medical consent letter for grandparents. Use our medical consent letter for grandparents samples as templates for your medical consent letter for grandparents.

Sample 1 – Medical Consent Letter For Grandparents

Your Name
Your Address
City, State, Zip Code

DATE

Name of Grandparent
Address of Grandparent
City, State, Zip Code

RE: Authorization for Medical Treatment of [Name of Child]

To Whom It May Concern:

The intent of this letter is to give [Name of Grandparent] the authorization to take my four-year-old son [Name of Son] to [Name of Doctor, Address of Doctor] and [Phone Number] or [Name of Hospital, Address of Hospital] and [Phone Number] if there is a medical emergency or medical attention is required when I am not available. 

[Name of Grandparent] is also permitted to give [Name of Son] OTC children’s Tylenol if he develops fever before reaching the doctor or hospital. [Name of Son] has no known intolerances or allergies to any medication.

If required by the hospital or doctor, [Name of Grandparent] has permission to give Insurance Information. This authorization becomes invalid on [Date].

Sincerely,

Parent’s Signature
Parent’s Name Printed and Relation to the Child i.e. mother, father of child
Date of signing

Copies to: Name of Hospital, Name of Doctor, Name of Grandparent, Name of Insurance Agent or Company

Sample 2 – Medical Consent Letter For Grandparents

Your Name
Your Address
City, State, Zip Code

DATE

RE: Medical Consent for Grandparents

To Whom It May Concern:

I, [Your Name], am the lawful guardian of the female child named below.

I give permission and consent to [Name, Address and Phone Number of Grandparents] to authorize medical treatment for [Full Name of Child] and date of birth.

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

Your Signature   DATE
Your Printed Name

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

Sample 3 – Medical Consent Letter For Grandparents

Your Name
Your Address
City, State, Zip Code

DATE

Name of Grandparent
Address of Grandparent
City, State, Zip Code

RE: Authorization for Medical Treatment of [Name of Child]

To Whom It May Concern:

I, [Your Name], do hereby consent to any medical care and the administration of anesthesia determined by a physician to be necessary for the welfare of my child while said child is under the care of [Name of Grandparent] and I am not reasonably available by telephone to give consent. 

This consent is granted from [DATE] and will expire on [DATE].

Your Signature   DATE
Your Printed Name

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

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