General Surgery Informed Consent Form Template

Patient Information

Name: _________________________ Date of Birth: ________________ Medical Record #: ________________ Date: ________________________

Procedure Details

Proposed Surgery: ________________________________________________ Side/Location: □ Right □ Left □ Bilateral □ Other: _________________

Consent Declaration

I, _________________________, hereby authorize Dr. _________________ and associates to perform the above-named surgical procedure.

Understanding of Procedure

1. The nature and purpose of the surgery has been explained to me
2. Alternative methods of treatment have been discussed
3. Possible risks and complications have been explained, including but not limited to:
   • Bleeding
   • Infection
   • Adverse reaction to anesthesia
   • Pain
   • Scarring
   • Need for additional procedures

Specific Risks Discussed

Patient Acknowledgment

• I understand no guarantees have been made regarding the outcome
• I have had the opportunity to ask questions and receive answers
• I understand that I may withdraw this consent at any time before surgery

Signatures

Patient/Legal Guardian: _________________________ Date: ____________ Time: ____________

Witness: _____________________________________ Date: ____________ Time: ____________

Physician: ____________________________________ Date: ____________ Time: ____________

Interpreter (if applicable)

Name: _______________________________________ Date: ____________ Time: ____________