AUTHORIZATION AND CONSENT FOR PROCEDURE
New River Health
497 Mall Road
Oak Hill, WV 25901
Phone: 304-469-2905
Patient Name
Patient Birthdate
MM
/
DD
/
YYYY
I hereby consent to the following procedure for my child named above:
Yes
No
Please select procedure below that you give consent for your child to receive.
Please select
Wart Removal
Punch Biopsy
Toenail Removal
Please select
The risks of the procedure are (but not limited to): bleeding, infection, reaction to numbing medications, faintness, and possibility of a thick scar.
Parent/Guardian Phone Number
Parent/Guardian Name
Signature of Parent/Guardian
Clear
Date
04
/
02
/
2025
Time
02
:
10
AM
OFFICE USE BELOW
Date Procedure Performed
Provider Performing Procedure
SUBMIT FORM
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