Trigger Finger Procedure Consent Form
Please review the information below and provide your consent for the trigger finger procedure.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Contact Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Procedure Confirmation
*
I confirm I am consenting to a trigger finger procedure on the affected finger(s).
I do not consent to the procedure.
Which finger(s) will be treated?
*
Thumb
Index Finger
Middle Finger
Ring Finger
Little Finger
Other
I understand the potential risks and complications of the procedure (such as infection, nerve injury, stiffness, recurrence, or incomplete release).
*
Yes, I understand and accept the risks.
No, I do not understand and would like to discuss further.
Have alternatives to the procedure been explained to you?
*
Yes, I am aware of alternatives.
No, I would like to discuss alternatives.
Please list any allergies or relevant medical conditions.
Signature (Please sign below to provide your consent for the trigger finger procedure.)
*
Submit Consent
Submit Consent
Should be Empty: