Surgery Informed Consent Form

Surgery Informed Consent Form
Date
MonthDayYear
Date
Name of Patient
First NameMiddle NameLast Name
Date of Birth
MonthDayYear
Date
Age
Gender
I hereby authorize the named Doctor/Surgeon below, and the assistants and associates whom he/she may designate to perform upon me the surgical procedure indicated below:
Name
First NameMiddle NameLast NameSuffix
Procedure
Unforeseen Necessary Operation
I have been oriented of the following for this procedure (all must be checked):
Under the premises above, I affirm that I understood the information stated and with full knowledge and consent that I accept the risks that entail in this procedure.
I understand the need for the use of anesthesia, its variations and its effects have been explained to me and I hereby give consent for the use of said anesthesia.
Name of Legal Guardian/Parent (if patient is below 18)
First NameMiddle NameLast Name
Relationship to Patient
Date Signed
MonthDayYear
Date
Signature of person giving consent
Clear
Does the patient need someone to sign for him/her?
Name of Representative
First NameMiddle NameLast Name
Relationship to patient
Date Signed
MonthDayYear
Date
Signature of Representative
Clear
Is a witness needed?
Name of Witness
First NameMiddle NameLast NameSuffix
Signature
Clear
Date Signed
MonthDayYear
Date
Doctor
Name of Doctor
First NameMiddle NameLast NameSuffix
Signature
Clear
Date Signed
MonthDayYear
Date
Should be Empty: