Consent to Treat Minor Children. Our office requires that a parent or guardian give specific permission if a minor child will receive treatment when the child is accompanied by someone other than the parent or guardian, or if the child presents by himself or herself. Parental authorization is given below so that your minor child may receive treatment without his or her parent or guardian being present. This authorization will become a part of the patient record. I, * Parent Name parent or legal guardian of:* Patient Name do hereby consent to any medical care and the administration of anesthesia determined by a physician of Georgia Spine and Orthopaedics to be necessary for the welfare of my child while said child is under the care of Erik T. Bendiks, Daryl Figa, and/or Vinson Smith and I am not reasonably available by telephone to give consent. This is in effect until revoked in writing by me. Parent Signature or Legal Guardian* Name of Parent or Legal Guardian* email* Phone number* Date*