The law requires that parental permission be obtained for operative procedures on minors. The
following consent form should be signed by the parents so that such procedures may promptly
occur. However, no operation will be performed, except in emergency situations, without
parents being contacted and fully informed. I give permission for such diagnostic, therapeutic
and operative procedures as may be deemed necessary for my child. I authorize release of
any medical information to process insurance claims and request payment of benefits to the
physicians or supplier for services described. I understand that should the insurance not cover
this illness/ injury, I will be responsible for payment in full of any charges incurred.