Colorectal Surgery Informed Consent and Treatment Agreement

Patient Information

Name: _________________________ Date of Birth: _________________ Medical Record #: ______________

Proposed Procedure

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

• Primary procedure: _________________________
• Additional planned procedures: _________________________

Understanding of Treatment

1. Nature of Procedure

   • I understand that the procedure involves surgery of the colon, rectum, or anal area
   • The specific surgical approach (open, laparoscopic, or robotic) has been discussed
   • The extent of tissue removal and potential need for ostomy has been explained

2. Risks and Complications

   • Bleeding and infection
   • Anastomotic leak
   • Temporary or permanent ostomy
   • Changes in bowel function
   • Urinary or sexual dysfunction
   • Anesthesia-related risks
   • Need for additional surgery

3. Expected Outcomes

   • Anticipated recovery timeline
   • Post-operative care requirements
   • Activity restrictions
   • Dietary modifications

Financial Agreement

• I understand my financial responsibilities
• Insurance coverage has been discussed
• Additional costs have been explained

Consent Declaration

I confirm that:

• All my questions have been answered satisfactorily
• I have had sufficient time to consider this decision
• I understand I may withdraw consent at any time before surgery

Signatures:

Patient: _________________________ Date: _________

Surgeon: _________________________ Date: _________

Witness: _________________________ Date: _________