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
MaleFemale
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 informed and it was explained to me that unforeseen conditions may arise where there might be a need for immediate surgical operation or procedure that is not within this informed consent. In such instance, I authorize the above-named surgeon to perform such immediate operation as deemed necessary.
I have been oriented of the following for this procedure (all must be checked):
The procedure to be done and its nature, the expected outcome and the risk involved including the possibilities of complications in the said procedure.The risk involved in ignoring or not going through the said procedure.Other alternative methods than the said procedure.
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?
Yes
Name of Representative
First NameMiddle NameLast Name
Relationship to patient
Date Signed
MonthDayYear
Date
Signature of Representative
Clear
Is a witness needed?
Yes
Name of Witness
First NameMiddle NameLast NameSuffix
Signature
Clear
Date Signed
MonthDayYear
Date
Doctor*
I have provided explanation with regard to the procedure to be taken and opportunity for the patient, representatives, guardian, and/or witnesses to ask his/her questions relating to the said procedure and all which were answered to the best of my knowledge and to the patient's satisfaction and consent.
Name of Doctor
First NameMiddle NameLast NameSuffix
Signature
Clear
Date Signed
MonthDayYear
Date
Should be Empty: