Consent For Spinal Surgery printable pdf download

 Dr. Robert H. Byers

Spine Center

 Dr. Brian W. Su

Consent for Spinal Surgery

PATIENT: ________________________________ DATE: _____________

Please read carefully and initial each numerical space. Not all sections may be related to your

particular surgery. Those items can be left blank. For example, if you are not having a fusion, items

related to hardware placement would not be relevant. If you are unsure if an item pertains to your

surgery, please ask your doctor.

1. ___

I have been strongly advised to carefully read and consider this operative permit. I

realize that it is important that I understand this material. I also understand that if

certain sections are not clear to me, I have the opportunity to ask for clarification. As I

read each section, I will place my initials in the space provided to indicate that I

understand what I have read.

2. ___

I am fully aware of the condition of my spine, and after careful consideration, I have

decided to undergo surgery to try to improve my condition. I hereby authorize my

doctors and their assistants to perform my surgery.

3. ___

I understand that this permit will discuss spinal surgery in a general way including

cervical, thoracic, lumbar or sacral disc removal; occipital, cervical, thoracic, lumbar or

sacral decompression including

laminectomy, foraminotomy, and/or facetectomy;

anterior or posterior occipital, cervical, thoracic, lumbar or sacral fusion with extension

to the occiput or sacrum/the use of metal or other non-metallic implants or substances

anteriorly or posteriorly to assist in fusion, deformity correction or stability success; the

use of instrumentation that may not be approved by the Food and Drug Administration

such as posterior occipital, cervical and thoracic screws (e.g. occipital screws, cervical

lateral mass screws, pedicle screws in the cervical and thoracic spine) as well as

various bio-implants, posterior spinal instrumentation with use of screws. This may also

include the use of instrumentation or other spinal implants in other areas of the spine

which to date have not been approved by the federal government but which the surgeon

believes is in my best interests as a patient.

4. ___

I understand that my doctors may be able to more comprehensively evaluate the

problems within my spine at the time of surgery. During the operation, they may deem it

necessary to vary the exact nature of the procedure in order to best treat my problem

and to obtain the best chance for a good outcome with the smallest possible operative

risk. I therefore consent to the performance of surgical procedures in addition to, or

different than, those now contemplated. If presently unforeseen conditions arise during

my surgery, I authorize, and fully consent to, my doctors and his associates performing

the necessary procedures.

5. ___

I understand that medical or non-medical personnel may be present to observe surgery.

I also understand that pictures or videotapes of my surgery or x-rays may be used for

educational purposes. I give my consent to these educational efforts and realize that

they in no way affect my care. My identity will not be disclosed if my x-rays, pictures or

videotapes are used at any time.

Consent For Spinal Surgery

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