Medical Release Form

A. Format

1. Identify the subject – You must first identify the person or people that will be covered by the medical release form. Particularly, you want to identify who will give authority to consent to the medical treatment, in the absence of a parent or guardian. Also, remember that an individual form will be required for each person that will be covered by a medical release form.

2. Detail each and every medical procedure that is not included on the consent form. The medical release form must legally specify whether all medical procedures are to be covered or if certain areas are not to be consented to. Specify in detail the procedures not allowed, or your medical release form may be found to be ineffective.

3. Provide a specific time frame for when the medical release form will cover. You can specify whether the release is valid for a certain time period or if it is effective until revoked. Open ended medical release forms must be more detailed and meet a stricter mode of writing.

4. If applicable, list any physicians or treatment places that are preferred. While this may only serve as a reference for a medical professional to indicate where the approving party desires to have medical treatment, it is usually not binding.

5. Provide the full contact information of the person who will be under the care of the appointed party. Provide their name, date of birth, address, and any other contact information. Each child must have their own form with their own contact information provided.

B. Instructions


1. State the subject – Identify in your form the following:

- Identify the person or people that will be covered by the medical release form.


- Identify who will give authority to consent to the medical treatment, in the absence of a parent or guardian.


- Remember that an individual form will be required for each person that will be covered by a medical release form.

2. Detail each and every medical procedure that is not included on the consent form.

- The medical release form must legally specify whether all medical procedures are to be covered or if certain areas are not to be consented to.

- Specify in detail the procedures not allowed, or your medical release form may be found to be ineffective.

3. Provide a specific time frame for when the medical release form will cover.

- Specify whether the release is valid for a certain time period or if it is effective until revoked.

- Open ended medical release forms must be more detailed and meet a stricter mode of writing.

4. If applicable, list any physicians or treatment places that are preferred.

- While this may only serve as a reference for a medical professional to indicate where the approving party desires to have medical treatment, it is usually not binding.

5. Provide the full contact information of the person who will be under the care of the appointed party. Provide:

- name


- date of birth


- address


- and any other contact information.

Each child must have their own form with their own contact information provided.

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