Caregiver Consent Form

Caregiver Consent Form
I hereby voluntarily give my consent to the caregiver and authorize him or her to care for my dependent(s), for the period stated in order to arrange for routine or emergency medical care and treatment to preserve the health of whom I state. I acknowledge that I am the responsible party for all the charges related to medical care and treatment during the time period stated.
The purpose of this consent is to give the caregiver the power and authority to handle my dependent(s) medical care and treatment. This consent will remain in effect until the end of the time period or it is revoked. Any question, concern, or problem regarding this authorization can be directed to me by phone or email that are stated under the "Contact Details" section of this consent form.
Parent/Legal Guardian Name
First NameLast Name
Dependent Information*
Caregiver Name
First NameLast Name
I do not authorize and give my consent to the caregiver on the following:
This authorization is effective between these dates:
From
MonthDayYear
Date
To
MonthDayYear
Date
Contact Details
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
IN WITNESS OF WHEREOF, I hereby sign this consent and acknowledge that I give my consent freely and knowingly.
Parent/Legal Guardian Name
First NameLast Name
Parent/Legal Guardian Signature
Clear
Date Signed
MonthDayYear
Date
Should be Empty: