Medical Statement of Consent

A medical statement of consent is one that is provided by a healthcare unit and agreed by the guardian or relative. This statement is obtained for future use for providing medical treatment especially in situation of an emergency. The medical statement of consent provides all medical history which includes all ailments and allergies so that treatment and diagnosis is taken up in the correct direction. The statement has to be signed by the guardian or parent in agreement of all the conditions specified for providing emergency medical care.

The statement can be provided and signed only by the legal guardian or parent in case the person is below the age of eighteen years. In all other cases where the person is above the age of eighteen years the person can make a self medical statement of consent. A sample medical statement of consent is provided here under for reference and best use.

Sample Medical Statement of Consent

Name of the applicant : Natalie Brown

Complete mailing address of applicant : #15, Newcastle upon Tyne, Tyne and Wear, London, NE15

Contact number of applicant : 112-333-4456

Email address of applicant :

Name of the parent of legal guardian if applicant is a minor : Michael Right

Address of legal guardian or parent (if different from above) : Same as above

Medical Statement of Consent :

I hereby authorize the medical emergency treatment of the applicant specified above in situation of sudden sickness or any other medical emergency such as injury etc which may occur. I have read and understood all the rules and regulations for the emergency medical treatment that will be provided wherein the medical organization will take due diligence and care. I agree that I will not raise a liability or claim damages for any loss or disability, death etc that may be sustained by the applicant during the course of treatment.

Signature of parent/guardian    _______________________________