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CONSENT TO MEDICAL OR SURGICAL CARE AND TREATMENT

NOTE TO PATIENT: There are risks involved in any procedure or treatment. It is not possible to guarantee or give assurance of a successful result. It is important that you clearly understand and agree to the planned surgery or treatment.

I authorize Dr.
and such physicians, associates, assistants and other personnel or the hospital or medical facility chosen by him or her to perform the following
(IN MEDICAL TERMS KNOWN AS):
(IN COMMON TERMS KNOWN AS):
and/or to do any other procedures that in their judgment may be advisable to my well-being, including such procedures as are considered medically advisable to remedy conditions discovered during the above  procedure.
  • GENERAL RISKS AND COMPLICATIONS. I am satisfied with my understanding of the more common risks ond complications of the treatment or procedure which are described generally on the back of this form. These risks include the risk of bleeding, infection, pain, anesthesia risks and death.
  • SPECIFIC RISKS AND COMPLICATIONS. I am satisfied with my understanding of specific risks of this procedure or treatment including (Doctor  to describe  specific  risks where  applicable):
  • ALTERNATIVE METHODS OF TREATMENT. I om satisfied with my understanding o\ alternative procedures or treatments and their possible benefits and risks including (Doctor to describe specific alternative procedures and complications where applicable):
  • NO TREATMENT. I am satisfied with my understanding of the possible consequences, outcomes or risks if no treatment is rendered.
  • SECOND OPINION. I have been offered the opportunity to seek a second opinion concerning the proposed treatment or proce-doe
  • ADDITIONAL OR DIFFERENT PROCEDURES DURING CARE AND TREATMENT. I understand that conditions may arise which are unforeseen at this time and that it may be necessary and advisable to perform operations and procedures different from, or in addition to, the procedure described. I authorize and consent to the performance of such additional or different operations and procedures as are considered necessary and advisable.
  • OTHEIt SERVICES. I consent to the performance of pathology and radiology services as needed and I further authorize the disposal of any severed tissue or member in accordance with customary hospital or medical facility practice.
  • PHOTOGRAPHY. I consent to the photographing, filming or videotaping of the treatment or procedure for educational or diagnos- tic use.
  • NO GUARANTEES. I understand there are risks involved in any procedure or treatment, and it is not possic›le to guarantee or give assurance of a successful result.
  • OTHER QUESTIONS. I am satisfied with my understanding of the nature of the procedure or treatments and all of my additional questions about the treatment or procedure have been answered.

I have read and been given a copy of this form.
DATE:
TIME
AMPM
PRINT PATIENT NAME:
SIGNATURE:
(PATIENT. PAI ENT OU LEGAL GUAI?DIAN)
TRANSLATED BY (IF APPLICABLE):
PHYSICIAN:
WITNESS.
PLEASE READ THE GENERAL INFORMATION ON BACK.
A MESSAGE TO PATIENTS ABOUT MEDICAL/SURGICAL RISKS

Medicine and surgery are generally safe, helpful and often lifesaving. However, medical or surgical procedures of any type involve the taking of risks, ranging from minor to serious (including the risk of death). It is impor- tant to be aware of the following possible risks before receiving the treatment you and your physician are planning. The following may be the reactions of your body to medical/surgical operations or procedures:

  1. INFECTION:Invasion of tissue by bacteria or other germs occurs to some degree whenever a cut, incision or puncture is made. In most instances, through the natural defense mechanisms of the body, healing of the affected area occurs without difficulty. In some instances antibiotic medicines are prescribed and at times additional surgical measures may be necessary to combat infection.

  2. HEMORRHAGE:The cutting of blood vessels causes bleeding and this occurs in every surgical incision. This bleeding is usually controlled without difficulty. At times, blood transfusions are required to replace blood loss. If blood transfusions are given, there are additional risks of liver inflammation, hepatitis, and the possibility of receiving Acquired Immune Deficiency Syndrome (AIDS). There is no absolutely reliable way to predict these unwanted reactions, some of which may be quite serious and even lead to death.

  3. DRUG REACTIONS:Unexpected allergies, lack of proper response to medications or illness caused by the prescribed drugs are possibilities. It is important for you to inform your physician and your anesthesiologist or certified registered nurse anesthetist of any problem you or your family have had with reactions to drugs and which medications you have taken in the past six months, including over-the-counter drugs, especially aspirin.

  4. ANESTHESIA REACTIONS:There may be unusual or unexpected responses to the gases, drugs or methods used to anesthetize you which can lead to difficulties with lung, heart or nerve function. Eating or drinking before anesthesia increases the risks of vomiting which may cause significant complications. Inform your anesthesiologist or certified registered nurse anesthetist of problems you and your family have had with anesthesia.

  5. BLOOD VESSEL INFLAMMATION AND CLOTTING:It is impossible to predict the occurrence of blood vessel inflammation and clotting problems. If blood clots form, they can move from where they formed to other areas of the body and cause injury.

  6. INJURY TO OTHER ORGANS: Because of the closeness of other organs to the area being operated on, there may be injury to other organs. The stress of surgery or the procedure may also harm other organ sys- tems of the body.

  7. OTHER RISKS:It is not possible to list all the possible risks and complications, and their variations, that may arise in any surgical operation or medical procedure. Each situation depends upon the purpose and nature of the operation or procedures. Your physician is willing to discuss further with you various details about other risks.

ALTERNATIVES TO TREATMENT

Although you and your doctor have decided upon this procedure, do not hesitate to discuss the reasons for the choice and the alternatives available for treatment of your condition. In addition, be sure to ask your doc- tor any other questions that you may have about your treatment.
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