Surgical Procedure Consent for Minor Patient
Patient Information
Minor's Name
Date of Birth
Patient ID/Number
Parent/Guardian Information
Parent/Guardian Name
Relationship to Patient
Contact Number
Procedure Details
Proposed Surgical Procedure
Name of Physician/Surgeon
Description of Procedure
Risks and Potential Complications Discussed
Alternative Treatments Discussed
Anesthesia Type
Consent
I, the undersigned, confirm that I have read and understood the information provided above and consent to the proposed surgical procedure for the minor patient named above.
Parent/Guardian Signature
Date
Physician/Surgeon Signature
Date