Surgical Informed Consent Form printable pdf download

SURGICAL INFORMED CONSENT FORM

CONSENT UPON ADMISSION FOR TREATMENT

do voluntarily consent to the following medical procedure(s):

Treating Doctor and Facility. The procedure will be performed by my Physician, Dr.

_______________________________, at

Center For Reconstructive Surgery. I have been informed that there are physicians who may have ownership in this surgery center. I

understand that I am free to choose another facility in which to receive services. I also understand Center For Reconstructive Surgery is

arranging for the equipment, technical support and clinical staff to be used in performing this procedure.

Basis of Consent. I give this voluntary consent after discussing with my Surgeon and agree that the procedure is an appropriate

course of medical treatment. In particular I have discussed with my Surgeon my general medical condition and allergies and I have

informed The Surgeon about any medication (including prescription and over-the-counters medications) that I am currently taking. My

Surgeon has fully explained the following:

•

the nature and purpose, the material risks, benefits, possibility of complications, alternative treatments and procedures

available and the consequences of the procedure.

I know that I may make requests for additional information about any of the above issues prior to the commencement of the procedure.

I also know medicine and surgery are not exact sciences and that no guarantees can be made concerning the results of the procedure.

My Surgeon has obtained my informed consent to the procedure. If I should have any questions or concerns regarding the nature or

results of the procedure or any other examination or treatment, I understand that I should ask my Surgeon.

Consent for Additional Procedures. I also give voluntary consent for any necessary routine diagnostic procedures and medical

treatment performed by my Surgeon as part of the above medical procedure. I also consent to the performance of other unforeseen

operations or procedures if my Surgeon determines they are required. Such a situation may arise, for example, if the procedure or

surgery discussed above discloses a previously unknown condition and my Surgeon determines, based on medical judgment, the

unforeseen operation or procedure is reasonably necessary to improve or maintain my health. I also understand other necessary

medical professionals, designated by my Surgeon, may also participate in my procedure.

Anesthesia. I understand that certain risks and benefits of anesthetics and medications. My Surgeon has explained to me that this

procedure will be conducted while I am under one of the following types of Anesthesia:

• General Anesthesia (medicine administered to render the patient unconscious)

• Monitored Anesthesia (sometimes referred to as “conscious sedation” in which the patient is conscious but fully sedated)

• Regional Anesthesia (numbing of a large portion of the body often through injection of medicine)

• Local Anesthesia (medicine given to temporarily stop the sensation of pain in a small, particular area of the body)

• Topical Anesthesia (commonly administered through eye drops or cream applied to the skin)

The risks and benefits of this type of anesthesia as well as the alternatives to receiving the recommended anesthesia have been

explained to me. I consent to the administration and performance of such anesthesia, and the administration of other necessary or

advisable medications, under the direction of the physician who is responsible for this service. I understand the anesthesiologist or

CRNA performing the anesthesia services has been granted privileges to provide these services at Center For Reconstructive Surgery

but may not be an employee of Center For Reconstructive Surgery or any affiliates.

Transportation and Care After the Procedure. I understand that it is my responsibility and I have arranged for a responsible adult to

drive me home and provide assistance following my surgery. I acknowledge that I have been advised not to drive until the effects of

any medications have worn off. I understand this to mean that I should not drive until the day after my procedure or as directed by my

Surgeon.

Educational Use Authority. I give permission for medical data concerning my procedure and subsequent treatment to be used in

clinical teaching by the Surgeon and others participating in my procedure and give permission to the photographing, videotaping or

televising of my surgery for teaching purposes, provided my identity is not revealed by the pictures or descriptive text accompanying

them. For the purpose of advancing medical education, I consent to the admittance of observers approved by the Facility’s Director in

the operating room. Under supervision of my Surgeon, I authorize clinical coaching of personnel in relation to my patient care.

Disposal of Medical Tissue. I consent to the disposal of any tissue removed during the procedure in accordance with customary

practices.

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Pt. Initials

Surgical Informed Consent Form

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