Surgical Consent and Release Form
Please read carefully and fill out this form to provide your consent for the surgical procedure.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Procedure Name
*
Surgeon's Name
*
Date of Surgery
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
I acknowledge that I have been informed about the risks, benefits, and alternatives of the procedure.
*
I release the medical staff and institution from any liability related to the procedure.
*
Additional Comments or Questions
*
Signature of Patient or Legal Guardian
*
Date Signed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: