Pediatric Orthopaedic Surgery Associates

Child Treatment Authorization

I hereby voluntarily consent to the rendering of such care, including diagnostic procedures, surgical and medical treatment by authorized members of Pediatric Orthopaedic Surgery Associates or their designees, as may in their professional judgment be necessary.

I hereby acknowledge that no guarantees have been made to me as to the effect of such examinations or treatment on my child’s condition.

I have read this form and certify that I understand its contents.
who will be caring for my child to make medical decisions regarding my child (listed above).

Signature ____________________________________ Date ___________