Child Treatment Authorization
Date of Birth
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.
I hereby give my consent for
who will be caring for my child to make medical decisions regarding my child (listed above).
For the period from
Signature ____________________________________ Date ___________