Authorization for Cardiac Surgery and Related Procedures

Patient Information

Name: ___________________________ Date of Birth: //___ Medical Record #: _________________ Date: //___

Procedure Authorization

I hereby authorize Dr. _________________________ and their surgical team to perform the following cardiac surgical procedure(s):

I understand this may include additional or different procedures than those planned if medical necessity requires them during the course of the authorized procedure.

Understanding and Acknowledgment

1. Nature of Procedure: I understand that the procedure(s) has been explained to me, including:

   • The nature and purpose of the procedure
   • Expected benefits and outcomes
   • Potential risks and complications
   • Alternative treatment options

2. Anesthesia Authorization: I consent to the administration of anesthesia as deemed necessary by the anesthesiologist.

3. Blood Products: I understand that blood products may be required and hereby:

   • Consent to receive blood products if needed
   • Decline blood products (additional forms required)

4. Medical Devices: I understand that medical devices may be implanted, including:

   • Cardiac valves
   • Pacemakers
   • Stents
   • Other cardiac assist devices

Certification and Signature

I certify that I have read and fully understand the above authorization, that all my questions have been answered satisfactorily, and that I accept the risks involved in this procedure.

Patient/Legal Guardian Signature: ___________________________ Date: //___

Witness Signature: ______________________________________ Date: //___

Physician Signature: ____________________________________ Date: //___

Interpreter (if applicable)

I have accurately interpreted the contents of this form to the patient in their preferred language.

Interpreter Signature: ___________________________________ Date: //___