PARENTAL MEDICAL CONSENT FOR A MINOR
Republic of the Philippines — Family authorization · Template v0.2.0
I, Maria Cristina Santos, of legal age, residing at 45 Mabini Street, Quezon City 1100, and reachable at +63 917 555 0123, am the mother of Mateo Santos Villanueva, born on June 14, 2015 (the "Child"). I give this consent on September 25, 2026.
1. My authority
The child's parents exercise parental authority jointly (Family Code, Article 211). Roberto Villanueva, the child's other parent, has been told of this consent and does not object.
2. Authorized adult and period
I authorize Teresita R. Gonzales, of legal age, the Child's Maternal aunt, residing at 12 Rizal Street, Baliuag, Bulacan 3006, and reachable at +63 918 555 0142 (the "Authorized Adult"), to arrange and consent to the care described below for the Child during October 1, 2026 to March 31, 2027.
3. Care covered
The Authorized Adult may consent to, and sign the provider's forms for: routine check-ups and outpatient consultations; medicines a doctor prescribes for the child; routine immunizations under the Department of Health schedule; emergency treatment when the signer cannot be reached in time.
For any care beyond routine care, the Authorized Adult shall try to reach me before the treatment begins.
4. Emergencies
Hospitals and clinics must give appropriate initial treatment in an emergency and may not demand a deposit first (Republic Act No. 8344 and Republic Act No. 10932). I ask the provider to contact me immediately in any emergency.
If I cannot be reached in time, the Authorized Adult may consent to emergency treatment that is needed to protect the Child's life or to prevent serious harm.
5. What this consent does not cover
This consent does not authorize surgery or general anesthesia, other than emergency treatment to protect life, or a blood transfusion other than in an emergency; clinical trials or organ donation; or HIV testing, mental-health treatment, or reproductive-health services, which follow their own laws and the provider's own consent process. It does not authorize travel outside the Philippines.
This consent does not transfer any part of my parental authority. I remain the Child's parent or guardian, and I may revoke this consent at any time by telling the Authorized Adult and the provider.
6. Health information
Health information the provider should know: Allergic to penicillin. Mild asthma; uses a salbutamol inhaler as needed.
Insurance or coverage: Maxicare HMO and PhilHealth dependent.
Preferred doctor, clinic, or hospital: Dr. Liza Ramos, St. Luke's Medical Center, Quezon City.
I allow the Authorized Adult to show this consent and to share the Child's necessary health information with the treating provider, and to share nothing more than the provider needs. Health information is sensitive personal information, and the provider's own privacy rules also apply.
7. Costs and reporting
The Child's insurance or HMO shall be used first, and I shall pay the balance.
After any treatment, the Authorized Adult shall tell me promptly what was done, keep the records and receipts, and give them to me.