CONSENT OF PARENT
SURGERY FOR MINOR
CONSENT OF PARENT
I, _________________________________, declare that:
1. I am
the _______________ (Father/Mother)
of _________________________, a minor, age __________ (___), born ____________ (Date), and I have full custody and
control of the minor.
hereby consent to a surgical operation to be performed on the minor, on or
about __________ (Date), by __________________________________________ (Surgeon).
The purpose of the operation is as follows: _______________________.
hereby consent that preceding, during, and following the operation, such
Surgeon may perform any other procedure deemed necessary or desirable in order
to achieve the purposes specified above or to correct any unhealthy condition
the Surgeon may encounter during the operation.
an operation requires the participation of numerous technicians, assistants,
nurses, and other personnel, I hereby consent to such participation by all
qualified medical personnel working under the supervision of such Surgeon
before, during, and after the operation to be performed.
hereby consent to the administration of any anesthetic as may be deemed
necessary by such Surgeon.
have been fully informed of the hazards and possible consequences of the
operation as well as possible alternative methods of treatment. I understand the
operation may not be successful and that there is
also a danger of the following unfavorable results:
CONSENT OF MINOR
I, ________________________________, have read the
above consent form signed by my __________ (Father/Mother),
and hereby join with __________ (Him/Her) in the consent. The above-noted Paragraph 6 has been
specifically pointed out to me, and I am aware of the possible unfavorable
consequences of the operation.
Signature of Minor Date