Consent of Parent for 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.

2. I 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: _______________________.

3. I 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.

4. Realizing 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.

5. I hereby consent to the administration of any anesthetic as may be deemed necessary by such Surgeon.

6. I 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: _____________________________________________________.

 

____________________________________         _________________
Signature                                                                    Date

 

____________________________________          _________________
Witness                                                                      Date

 

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

 

____________________________________          _________________
Witness                                                                      Date

Other Forms You May Need

• Authorization for Minor's Medical Treatment