CONSENT FOR TREATMENT OF NEWBORN
I, _____________________________ (Name), a patient at _____________________ (Hospital), authorize the attending physicians of the staff to give any medical or surgical treatment, including X-ray examinations, injections, blood transfusions, anesthesia, operations, removal of tissue and disposal of tissue as may be deemed advisable or necessary for my newborn infant(s).
________________________________ Signature of Mother
___________________ Date
________________________________ Witness
___________________ Date