Physician's Surgery and Procedure Consent Form
[For completion at conclusion of informed consent discussion]
I consent to the performance of the following operation or procedure (technical name)_________________________
(myself or name of patient)
The purpose of this operation or procedure is (lay language) and
will be performed by and whomever (s)he may designate as assistants.
My physician has explained the nature and purpose of the operation or procedure, anesthesia, the
benefits and risks of the operation or procedure, the possibilities of complications, and the alternatives to this operation
or procedure and their risks and benefits to me.
My physician has explained to me that a satisfactory result is expected, but that the following are
some of the complications or effects that could or may occur: bleeding, infection, damage to adjacent tissues or organs,
swelling, pain, suture reaction, delayed healing, scarring, anesthesia or medication reaction, recurrence, additional
operations, and in rare instances, paralysis or death; other:
No one has given me a guarantee or assurance about the results that may be obtained.
I (we) understand that my physician may encounter or discover other or different conditions
which require additional or different procedures than those planned. I (we) authorize my physician, and associated
technical assistants, and other health care providers to perform such other procedures which are advisable, in their
professional judgment, for my immediate well-being.
I have informed my physi