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Back to Forms for 'Parent and Child'.








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




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


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