Spine Care Specialists Surgical Consent Form printable pdf download

Spine Care Specialists

Orthopaedic Specialists of Northwest Indiana, P.C.

Nicole F. Einhorn, M.D.

730-45

Street

Louis A. Gluek III, M.D.

Munster, Indiana 46321

Joseph D. Hecht, M.D.

Telephone (219) 924-3300

Nitin Khanna, M.D.

Facsimile (219) 922-5424

Dwight S. Tyndall, M.D.

SURGICAL CONSENT FORM

Initial

Below

I authorize DR. _________________________ (and such assistants and associates as may be

selected or designated by him) to perform the following surgical procedure on me:

______________________________________________________________________________

I understand that every surgical procedure entails risks. The risks of this procedure include, but

are not limited to, injury to the blood vessels and/or bleeding, injury to the nerves and/or

muscles, injury to the bones and/or tendons or ligaments, and infection.

I understand that this surgery may not completely resolve my complaints and that I may have

residual symptoms after the surgery. I understand that I may even require additional surgery.

I have received and reviewed the information and materials given to me regarding this surgical

procedure and that all of my questions have been answered. I have been provided with the

information I need to make a decision to undergo the recommended surgical procedure.

I understand that there are other treatment options available and that I could continue to receive

non-surgical treatments such as medication, physical therapy, and pain management. I also

understand that I could undergo a different surgical procedure such as a fusion without

instrumentation or with different instrumentation. I have discussed these options with my

physician and I have voluntarily chosen to undergo this surgery.

I understand that I can obtain the opinion of another physician before I undergo this procedure. If

requested, my physician will provide me with the names or other doctors with whom I can

discuss my condition and the proposed treatment.

I acknowledge that I have received no warranties or guarantees with respect to the benefits to be

realized or the risks and consequences of the recommended procedure.

I have reviewed the entire form and have initialed each paragraph to indicate my agreement with

its contents.

Date:

_____________________

_______________________________

Patient’s Signature

Date:

_____________________

_______________________________

Physician’s Signature

Date:

_____________________

_______________________________

Witness Signature

Spine Care Specialists Surgical Consent Form

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