Brachial Plexus Surgery Consent Form

First Name

Last Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Scheduled Surgery Date

Date

Surgeon Name

First NameMiddle NameLast Name

Facility / Clinic Name

Diagnosis or Reason for Surgery

Affected Side / Arm

Additional Procedure Notes

Current medications

Medication allergies

Latex allergy

Prior surgeries or procedures

History of bleeding or clotting problems

History of anesthesia complications

Major health conditions and other details

Consent Information

Acknowledgment and Consent

I understand the purpose, expected benefits, common risks and complications, possible need for additional procedures, and alternatives such as non-surgical treatment or no treatment. I had the opportunity to ask questions and I agree to proceed.

Patient Signature

Date Signed

Date

Brachial Plexus Surgery Consent Form

Patient Information

Surgery and Provider Details

Medical History and Safety Screening

Procedure Understanding and Consent

Signature and Date