Surgical Informed Consent Form Page 2
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2Additional Testing of Blood. In the event someone associated with my procedure becomes accidentally exposed to my blood or
bodily fluids – such as in the case of an accidental needle stick or direct contact with their skin or mucous membrane with my blood or
bodily fluids – I consent to the testing of my blood for blood-borne pathogens, including HIV and Hepatitis.
Advance Directives. I understand that advance directives are not honored at Center For Reconstructive Surgery.I understand that if
an emergency medical condition should occur I will be transferred to the closest hospital for further evaluation and treatment. if I have
an advanced directive or living will, the surgery center will still transfer me to a hospital which will make the decisions about following
any advanced directive or living will. If I should be transferred to a hospital, I authorize to the hospital to release copies of my medical
records to the surgery center to review the episode of care.
I have the following:
Copy given to SurgeryCenter
[ ] Living Will
[ ]
[ ] Health care surrogate, proxy or durable power of attorney
[ ]
[ ] Power of Attorney
[ ]
[ ] Evidence of Guardianship
[ ]
[ ] None
Legal Relationship between Surgery Center and Physicians. I understand that all physicians furnishing services to the patient,
including mySurgeon, an anesthesia provider, radiologist and pathologist are independent contractors with the patient and are not
employees or agents of Center For Reconstructive Surgery . I understand that I am under the care and supervision of my Surgeon and
that the surgery center and its staff carry out instructions of my Surgeon.
Radiology and Lab Services. . My Surgeon may also send specimens to a professional pathology laboratory for a pathological
diagnosis. Pathology services are billed separately by those individual laboratories.
Equipment/supplies. I understand that my Surgeon may choose to prescribe additional supplies or equipment which may be billed
separately.
Personal Effects. I release Center for Reconstructive Surgery from any responsibility for loss or damage to.
money, jewelry, or other personal effects that I bring into Center for Reconstructive Surgery .
I acknowledge that I have received the following items prior to the procedure:
Patient Rights and Responsibilities Physician ownership information.
The policy about advanced directivesPatient Privacy
I CERTIFY that I have been given enough time to read and fully understand the above information that the procedure has been fully
explained by my Surgeon and I authorize and consent to the performance of the procedure.
Patient’s Signature
Printed Name
Date & Time
If patient’s personal representative, state relationship and authority:
Representative’s Signature
Relationship
Printed Name
Date & Time
Witness’ Signature
Printed Name
Date & Time
Physician’s Signature
Anesthesiologist/CRNA (if Applicable)
I have reviewed the anesthesia stated and procedure risks for this patient
and for this procedure.
Page 2 of 2
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Pt. Initials
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