Attachment C "Consent to Medical, Dental and Surgical Invasive Procedures" - Georgia (United States)

What Is Attachment C?

This is a legal form that was released by the Georgia Department of Juvenile Justice - a government authority operating within Georgia (United States). As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Georgia Department of Juvenile Justice;
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  • Fill out the form in our online filing application.

Download a printable version of Attachment C by clicking the link below or browse more documents and templates provided by the Georgia Department of Juvenile Justice.

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Download Attachment C "Consent to Medical, Dental and Surgical Invasive Procedures" - Georgia (United States)

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Attachment C, DJJ 11.13
CONSENT TO MEDICAL, DENTAL AND SURGICAL
INVASIVE PROCEDURES
Facility:
Youth’s Name:
DOB:
I request Dr.
and such associates and assistants as he/she may deem necessary
or direct to perform upon
the following procedure (s):
If during the course of the procedure (s), the discovery of unforeseen conditions requires, in the judgement of the
persons described above, different procedure(s) than those planned, I authorize such different procedure(s) as are
deemed appropriate.
I understand that no warranty or promise has been made to me regarding the outcome of the proposed procedure(s)
or cure of any condition, and the risk presented by the proposed procedure(s), have been explained to me by
Dr.
, as have been the alternative to procedure(s) planned.
I consent to the administration of anesthesia and to the use of such anesthetic agents and as many other drugs as are
deemed necessary and advisable, and understand that anesthesia and other drugs present additional risk and
hazards.
I have been given an opportunity to ask questions about my, or the youth's condition, alternative forms of
anesthesia and treatment, risks of non-treatment, the procedure(s) to be used, and the risks and hazards involved,
and I believe that I have sufficient information to give this informed consent. I have read, or have had read to me,
this form and I understand its content.
If I change my address, I will keep the court informed regarding how to reach me in case of an emergency.
Parent/Guardian Signature
Relationship
Date and Time
Witness Signature
Date and Time
(If signed on behalf of patient, indicate relationship to patient and reason patient cannot sign form):
I have explained the matters indicated above relating to the operation and/or procedure(s) and the risks,
consequences and alternative(s). The patient and/or authorized person indicated appear to understand and have
consented to the procedure described.
Physician's Signature
Date and Time
Attachment C, DJJ 11.13
CONSENT TO MEDICAL, DENTAL AND SURGICAL
INVASIVE PROCEDURES
Facility:
Youth’s Name:
DOB:
I request Dr.
and such associates and assistants as he/she may deem necessary
or direct to perform upon
the following procedure (s):
If during the course of the procedure (s), the discovery of unforeseen conditions requires, in the judgement of the
persons described above, different procedure(s) than those planned, I authorize such different procedure(s) as are
deemed appropriate.
I understand that no warranty or promise has been made to me regarding the outcome of the proposed procedure(s)
or cure of any condition, and the risk presented by the proposed procedure(s), have been explained to me by
Dr.
, as have been the alternative to procedure(s) planned.
I consent to the administration of anesthesia and to the use of such anesthetic agents and as many other drugs as are
deemed necessary and advisable, and understand that anesthesia and other drugs present additional risk and
hazards.
I have been given an opportunity to ask questions about my, or the youth's condition, alternative forms of
anesthesia and treatment, risks of non-treatment, the procedure(s) to be used, and the risks and hazards involved,
and I believe that I have sufficient information to give this informed consent. I have read, or have had read to me,
this form and I understand its content.
If I change my address, I will keep the court informed regarding how to reach me in case of an emergency.
Parent/Guardian Signature
Relationship
Date and Time
Witness Signature
Date and Time
(If signed on behalf of patient, indicate relationship to patient and reason patient cannot sign form):
I have explained the matters indicated above relating to the operation and/or procedure(s) and the risks,
consequences and alternative(s). The patient and/or authorized person indicated appear to understand and have
consented to the procedure described.
Physician's Signature
Date and Time