Cardiac Surgery Informed Consent Form

Patient Information

Name: _________________________ Date of Birth: __________________ Medical Record #: _______________

Procedure Details

Proposed Surgery: _______________ Side/Location: _________________ Surgeon: ______________________

Nature of Procedure

I understand that I will undergo cardiac surgery for the following condition:

Surgical Procedure Description

The procedure will involve:

• Administration of general anesthesia
• Sternotomy (opening of the chest)
• Use of cardiopulmonary bypass (heart-lung machine) if necessary
• Specific cardiac procedure: ________________________

Benefits and Alternatives

Expected Benefits

• Relief of cardiac symptoms
• Improved heart function
• Enhanced quality of life

Alternative Treatments

• Medical management
• Catheter-based interventions
• No treatment

Risks and Complications

I understand the following risks:

Common Risks (>5%)

• Pain and discomfort
• Wound infection
• Irregular heart rhythm
• Bleeding requiring transfusion

Serious Risks (1-5%)

• Stroke
• Heart attack
• Deep infection
• Kidney dysfunction

Rare but Serious Risks (<1%)

• Death
• Permanent disability
• Need for reoperation

Patient Acknowledgment

I confirm that:

• The procedure has been explained to me
• I have had the opportunity to ask questions
• I understand the risks and benefits
• I agree to proceed with the surgery

Patient Signature: _________________ Date: _________ Witness Signature: _________________ Date: _________ Surgeon Signature: _________________ Date: _________