If you write a letter and get in notarized, that often suffices for hospitals.  Each hospital and physician's office has their own. There is no standard form since it must relate to the laws of the area of guardianship. Check with the emergency room that grandma is likely to use or ask the pediatrician in the area where she will be staying for what they use.

Wayne Yankus, MD, FAAP
expert panelist: pediatrics

Hi parent!

You're so smart to do this.  While a hospital would have to treat a life threatening illness or injury, they would likely NOT treat a mild illness or injury without such a document.  

You can write a medical consent letter that includes:
- Your name, mailing address, and home phone numbers
- Your contact information during the trip (or an indication that you will not be able to be reached)
- Your mom's name and contact information (as it appears on her drivers license or other photo ID"
- Your daughter's pediatrician and the office's phone number.
- Your daughter's dentist and the office's phone number.
- Information about your daughter (Age, birth date, medications she currently takes, any allergies, illnesses or other health related information.
- The exact dates when your mom is serving as temporary guardian. ("My mother [her name here] has agreed to serve as temporary guardian of my daughter [her name here] from the period of DATE to DATE while my husband and I [vacation, travel for business, etc].
- This sentence:  "I authorize my mother to consent to any medical or dental examinations or treatments for my daughter.  I further authorize my mother to access any medical or insurance records related to the health care treatment of [daughter's name] during the period noted above."
- Your signature (and your daughter's father if he's also a legal guardian)
Your mom's signature


To be safe, you should have a witness (not your mom) sign the document to indicate that he/she saw you sign.  To be REALLY safe go to your local notary public to have them witness.  

I also found a consent form template from Bloomington Hospital which I'll post in the Resource section below.

Have a great summer!