Healthcare Minor Surgery Consent Form

HEALTHCARE MINOR SURGERY CONSENT FORM

Patient Name:   Date of Birth:   Age:

Parent / Legal Guardian Information

Insurance Information

Medical History

Procedure & Anesthesia

Proposed Procedure:

Indication / Reason for Procedure:

Performing Surgeon / Clinician:   Facility:

Scheduled Date:   Estimated Duration:

Type of anesthesia to be used (check all that apply):

Local anesthesia (numbing at site)   Sedation / Monitored anesthesia care   General anesthesia

Risks, Benefits, and Alternatives

I acknowledge that the risks, expected benefits, and reasonable alternatives to the proposed procedure and anesthesia have been explained to me in language I understand. The following risks have been discussed and are not limited to: infection; bleeding; scarring; nerve injury or weakness; incomplete resolution of the problem; adverse reaction to medications or anesthesia; need for additional procedures; and, in rare cases, serious harm or death. Specific risks related to this procedure include: pain at the site, delayed healing, and the potential need for conversion to a more extensive procedure.

Specific Authorizations

The undersigned authorizes the clinician(s) and facility to perform the procedure described above, including any intraoperative or immediate postoperative procedures that become necessary for the minor's safety. I also authorize routine and special diagnostic procedures and such additional treatment as may be necessary in the event of complications.

I authorize photographs, video, or other imaging for medical records, care coordination, or teaching purposes. I understand that identifying information will be protected.

I authorize administration of blood or blood products if deemed necessary for the minor's safety. (If refused, note on medical record.)

I consent to appropriate disposition or pathological examination of any tissue removed.

HIPAA & Release of Information

By signing below, I acknowledge that I have received or been offered the facility's notice of privacy practices and authorize release of medical information to insurance carriers and other providers as necessary for treatment, payment, and healthcare operations. I permit communication from the facility and clinicians at the contact information provided.

I acknowledge receipt of the privacy notice and authorize release of information as described above.

Authorization Period

This authorization is effective for the date of the procedure and related care unless an earlier expiration date is specified: Expiration Date:

Certification & Guardian Representation

I certify that I am the parent or legal guardian of the minor named above and that I have the legal authority to consent to the proposed surgery and related treatment. I confirm that I have read and understand this consent, that all questions have been answered to my satisfaction, and that I authorize the healthcare team to proceed with the care described.

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