Authorization for Colorectal Surgery and Related Procedures

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record #: ______________ Date: _____________________

Procedure Authorization

I hereby authorize Dr. _________________ and associates to perform the following procedure(s):

Consent Declarations

1. Nature of Procedure

   • I understand the nature of the proposed procedure(s)
   • The potential risks, benefits, and alternatives have been explained to me
   • I acknowledge that no guarantees have been made regarding the outcome

2. Additional Procedures

   • I authorize the performance of additional procedures if deemed necessary during the operation
   • This includes but is not limited to management of unexpected conditions or complications

3. Anesthesia Consent

   • I consent to the administration of anesthesia as required
   • I understand the risks associated with anesthesia

4. Use of Medical Devices

   • I consent to the placement of any necessary medical devices
   • This may include temporary or permanent stomas, drains, or other surgical appliances

Acknowledgments

• I have had the opportunity to ask questions about the procedure
• I have received pre-operative instructions
• I understand the post-operative care requirements

Signatures

Patient/Legal Guardian: _________________________ Date: __________

Witness: _____________________________________ Date: __________

Physician: ____________________________________ Date: __________