Informed Consent for Minor Surgery in Pediatrics
Patient Information
Full Name of Patient:
Date of Birth:
Medical Record Number:
Parent/Guardian Information
Full Name of Parent/Guardian:
Relationship to Patient:
Contact Number:
Description of Proposed Procedure
Name of Procedure:
Reason for Procedure:
Risks and Benefits
Risks/Complications Discussed:
Possible Benefits:
Alternatives
Alternatives to Proposed Surgery:
Consequences of Not Performing Surgery:
Anesthesia
Type of Anesthesia Discussed:
Risks and Side Effects:
Questions
Questions asked by parent/guardian and answers provided:
Consent Statement
I hereby confirm that the above information has been explained to me, and all of my questions have been answered. I have had the opportunity to discuss the proposed procedure, its risks, benefits, alternatives, and consequences. I consent to proceed with the surgery as described above.
Parent/Guardian Signature:
Date:
Provider/Witness Signature:
Date: