Form # Mcg294 - Brachial-Basilic Av Fistula (2013) Page 2
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1
2Georgia Regents Medical Center
Patient Label
INFORMED CONSENT FOR SURGICAL
AND/OR DIAGNOSTIC PROCEDURES
For Procedure(s): ______________________________________________________________________________
Placement of brachial-basilic transposed upper arm arteriovenous fistula
15. By signing this form, I acknowledge that I have read it carefully or had it read or explained to me and that I understand this
form and its contents, and I hereby voluntarily consent to and request GRMC, its medical staff, and all other medical personnel
which may otherwise be involved in my treatment to perform the procedure(s) described or otherwise referred to herein.
(This consent will be valid for thirty (30) days from date of signature unless revoked.)
______________________________________________________________________________
Patient / Guardian [Printed Name]:
________________________________________________________________
Date: _____________ Time: __________________
Patient / Guardian [Signature]
Month/Date/Year
(Military Time)
______________________________________________________________________________________
Witness [Printed Name]:
________________________________________________________________
Date: _____________ Time: __________________
Witness
[Signature]
Month/Date/Year
(Military Time)
I
certify that I explained the above referenced procedure(s) to
, ___________________________________________________________,
[Printed Name of Practitioner]
______________________________________________________________________________,
on ________________________.
[Printed Name of Patient/Guardian]
MM
DD
YY
I further certify that the patient was given an opportunity to ask questions regarding the procedure(s), potential risks, and possible
alternatives.
_______________________________________________________________________ Date: _____________ Time: ___________________
[Physician Signature]
Month/Date/Year
(Military Time)
_____________________________________________________________________________________________________________________________________________________
OPERATIVE CONSENT FOR TRANSFUSION
SECTION NOT APPLICABLE FOR THIS PROCEDURE
I understand that it may be deemed necessary by my surgeon and/or anesthesiologist during or after surgery to give me blood or
blood component in order to restore blood volume or clotting factors and/or to improve oxygen carrying capacity. Though the
risks today are very low and blood is screened for transmittable diseases, potential risks of the transfusion of blood or blood
components include, but are not limited to , transfusion reactions, such as headache, fever, chills, rash, difficulty breathing,
excessive blood volume, and blood-borne infections. Potential risks of not receiving blood or blood components include bleeding,
stroke, heart attack, and death. Potential alternatives to receiving blood or blood components that may be available are self-
donation, directed donation, or cell saving technologies.
CONSENT
DO NOT CONSENT
________________________________________________________________________ Date: _____________ Time: __________________
Patient / Legal Guardian* [Signature]
Month/Date/Year
(Military Time)
________________________________________________________________________ Date: _____________ Time: __________________
Witness Signature
Month/Date/Year
(Military Time)
* I, __________________________________________, hereby represent and certify that I am the spouse, parent, or legal
guardian of the patient, as evidenced by my signature above
.
_____________________________________________________________________________________________________________________________________________________
TELEPHONE CONSENT
When a telephone consent is being obtained, the above information must be read to the person consenting.
I, _______________________, read the above information to ______________________ at ___________ Date: ___________.
(Name of Practitioner)
(Name of Person Consenting)
(Military Time)
Month/Date/Year
_________________________states that he/she is ___________________ of ______________________________ and he/she
(Name of Person Consenting)
(Relationship to Patient)
(Name of Patient)
authorized the treatment/procedure described above and has been provided an opportunity to ask any desired questions.
ate: _____________ Time: _____________
__________________________________________________________________________________ D
____
Practitioner’s Signature/ Title
Month/Date/Year
(Military Time)
I witnessed and overheard the telephone conversation in which the above consent was given to perform the desired
treatment/procedure.
____________________________________________________________
__________________________________________________________
Signature of First Witness
Signature of Second Witness
_____________________________________________________________
__________________________________________________________
Address of First Witness
Address of Second Witness
*CONSENT*
Rev. 8/8/13; Form # MCG294
Page 2 of 2
CONSENT
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