Affix Patient Identification

Sticker in this Area

CONSENT FOR SURGICAL, MEDICAL, OR DIAGNOSTIC PROCEDURES

Please read this entire form carefully. Before signing it, ask any questions you may have.
Your consent is valid until you withdraw it.

**I hereby authorize Dr. ________________________________ with hospital personnel and/or

other
(physician’s full name)

trained persons of his/her choice to perform upon _________________________ the following

surgical,
(patient’s full name)

medical, or diagnostic procedure(s)________________________________________________________

(Please list site and side if appropriate)

_____________________________________________________________________________________

The benefits, risks, complications, and alternatives to the above procedure(s) have been
explained to me.

I further authorize my physician to perform any other procedure that in his/her judgment is
advisable for my well-being. This additional authority is extended as I recognize that during
the above-listed procedure(s), unforeseen conditions may require different or additional
procedures.

**I hereby consent to the administration of such anesthetics as are necessary; the choice of
anesthetic to be used shall be made by the members of the Department of Anesthesiology. I
understand that anesthesia involves risks that are in addition to those resulting from the
operation itself including, but not limited to, dental injury, hoarseness, vocal cord injury,
infection, nerve injury, corneal abrasion, seizures, heart attack, stroke and even death.

**I hereby consent to the administration of blood or blood products as deemed advisable
during the course of my procedure. The risks, benefits, and alternatives to receiving blood
and blood products have been explained to me.

I certify that I have read and understand the above consent statements. In addition, I have
been offered the opportunity to ask my physician any questions I have regarding the
procedure(s) to be performed and they have been answered to my satisfaction. I
acknowledge that I have been given no guarantee or assurance as to the results that may
be obtained from the procedure(s).

_______________________________________ _______________________________________
Signature of Patient Date and Time Physician Signature Date
and Time

_______________________________________ _______________________________________
Relationship to Patient if Decision Maker Physician Print Name

_______________________________________
Witness Signature Date and Time
_______________________________________
Witness Print Name