PARC Surgical Center - Disclosure and Consent Form

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Patient Name

First Name

Last Name

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Patient Birth Date

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TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you make the decision whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed, so you may give or withhold your consent to the procedure.

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Please choose the type of surgery your child is having:

Hypospadias

Phalloplasty

Other

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I/we voluntarily request Warren Snodgrass, MD and Nicol Bush, MD, MSCS as my physicians or healthcare provider(s), and such associates, technical assistants, and other healthcare providers as they may deem necessary, to treat my condition which has been explained to me.

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I/we voluntarily request Warren Snodgrass, MD and Nicol Bush, MD, MSCS as my physicians or healthcare provider(s), and such associates, technical assistants, and other healthcare providers as they may deem necessary, to treat my condition which has been explained to me as: Chordee.

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I/we voluntarily request Warren Snodgrass, MD and Nicol Bush, MD, MSCS as my physicians or healthcare provider(s), and such associates, technical assistants, and other healthcare providers as they may deem necessary, to treat my condition which has been explained to me as: Hypospadias.

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Just as there may be risks and hazards in continuing my present condition without treatment, there are also risks and hazards related to the performance of the surgical, medical and/or diagnostic procedures planned for me. I/we realize that common to surgical, medical and/or diagnostic procedures is the potential for infection, blood clots in veins and lungs, hemorrhage, allergic reactions, and even death. I/we also realize that risks and hazards may occur in connection with this particular procedure.

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Phalloplasty - Just as there may be risks and hazards in continuing my present condition without treatment, there are also risks and hazards related to the performance of the surgical, medical and/or diagnostic procedures planned for me. I (we) realize that common to surgical, medical and/or diagnostic procedures is the potential for infection, blood clots in veins and lungs, hemorrhage, allergic reactions, and even death. I (we) also realize that the following risks and hazards may occur in connection with this particular procedure:

Persistent or Recurrent Curvature.

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Hypospadias - Just as there may be risks and hazards in continuing my present condition without treatment, there are also risks and hazards related to the performance of the surgical, medical and/or diagnostic procedures planned for me. I (we) realize that common to surgical, medical and/or diagnostic procedures is the potential for infection, blood clots in veins and lungs, hemorrhage, allergic reactions, and even death. I (we) also realize that the following risks and hazards may occur in connection with this particular procedure:

Leakage of Urine of Surgical Site (fistula), Urethral Stricture, Recurrent Hypospadias.

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I/we understand that the following surgical, medical, and/or diagnostic procedures are planned for me and I (we) voluntarily consent and authorize these procedures.

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I/we understand that the following surgical, medical, and/or diagnostic procedures are planned for me and I (we) voluntarily consent and authorize these procedures:

Phalloplasty, possible hypospadias repair

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I/we understand that the following surgical, medical, and/or diagnostic procedures are planned for me and I (we) voluntarily consent and authorize these procedures:

Hypospadias repair

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I/we understand that my physician(s) may discover other or different conditions which require additional or different procedures that those planned.

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I/we authorize my physician(s) or health care provider(s), and such associates, technical assistants and other health care providers to perform such other procedures which are advisable in their professional judgement.

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I/we consent to the photographing or videotaping of the operations or procedures to be performed, including appropriate portions of my body, for medical, scientific, or educational purposes, providing my identity is not revealed by descriptive texts accompanying the pictures/videos.

YESNO

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Please Initial to Acknowledge Your Consent or Refusal to Consent:Use your finger or mouse to draw your initials.

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I/we agree to the possible presence of a scientific observer in the operating room during my surgical care should my surgeon(s) make such a request. I understand that said observer is not in anyway associated with PARC Surgical Center. I hereby release PARC Surgical Center, its agents, assigns and successors, from any and all liability, which may result from the presence of a scientific observer in the operating room.

YESNO

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Please Initial to Acknowledge Your Consent or Refusal to Consent:Use your finger or mouse to draw your initials.

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I/we consent to the use of blood and blood products as deemed necessary. I/we understand that the following risks and hazards may occur in connection with the use of blood and blood products: Serious infection including but not limited to hepatitis and HIV which can lead to organ damage and permanent impairment. Transfusion related injury resulting in impairment of lungs, heart, liver, kidneys and immune system. Severe allergic reaction, potentially fatal.

YESNO

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Please Initial to Acknowledge Your Consent or Refusal to Consent:Use your finger or mouse to draw your initials.

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I (we) understand that no warranty or guarantee has been made to me as a result or cure.

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I/we have been given an opportunity to ask questions about my condition, alternative forms of treatments, risks of non treatment, the procedures to be used, and the risks and hazards involved, and I/we believe that I/we have sufficient information to give this informed consent. I/we certify that this form has been fully explained to me/us, that I/we have read it or have had it read to me/us, that the blank spaces have been filled in and that I/we understand its contents.

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Name of Parent or Legal Guardian

First Name

Last Name

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Relationship to Patient

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Date

Hour

Minutes

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---------------------- For office use only ---------------------

WITNESS OF SIGNATURE ONLY:_______________________________

PHYSICIAN SIGNATURE:_____________________________________

DATE/TIME:__________________________________