Authorization for Surgical Treatment and Procedures

Patient Information

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

Authorization Statement

I, _________________________________, hereby authorize Dr. _________________________ and associates/assistants of their choice to perform the following surgical procedure(s):

Acknowledgments

• I understand that during the course of the procedure(s), unforeseen conditions may necessitate additional or different procedures than those outlined above.
• I authorize my surgeon and their associates to perform such additional procedures that are deemed necessary or desirable in their professional judgment.
• I acknowledge that no guarantees have been made concerning the results of this procedure.

Anesthesia Authorization

I consent to the administration of such anesthetics as may be considered necessary or advisable by the physician responsible for this service.

Blood Products Authorization

• I consent to the administration of blood or blood products if deemed necessary
• I decline the administration of blood or blood products

Photography Authorization

I consent to the photographing or videotaping of the procedure(s) for medical, scientific, or educational purposes, provided my identity is not revealed.

Signatures

Patient/Legal Guardian: _________________________ Date: _________ Time: _______

Witness: _____________________________________ Date: _________ Time: _______

Physician: ____________________________________ Date: _________ Time: _______

Emergency Contact

Name: _________________________ Relationship: _______________ Phone: ________________________

This authorization is valid for 30 days from the date of signature