Informed Consent for Colorectal Surgery

PATIENT INFORMATION

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

PROCEDURE DETAILS

Proposed Surgery: ______________________________________________ Side/Location: □ Right □ Left □ Bilateral □ Other: ________________

CONDITION AND PROCEDURE

I understand that I have been diagnosed with: ________________________________

The proposed procedure has been explained to me as: _________________________

RISKS AND COMPLICATIONS

I understand that this procedure carries risks including but not limited to:

Common Risks (>5%)

• Post-operative pain and discomfort
• Temporary bowel dysfunction
• Wound infection
• Bleeding
• Temporary urinary difficulties

Less Common Risks (1-5%)

• Anastomotic leak
• Need for temporary or permanent stoma
• Deep vein thrombosis
• Adhesions
• Return to operating room

Rare Risks (<1%)

• Damage to nearby organs
• Severe infection
• Mortality
• Sexual/urinary dysfunction

ALTERNATIVES

I understand the following alternatives have been discussed:

1. Conservative management
2. Medical therapy
3. No treatment

PATIENT ACKNOWLEDGMENT

I confirm that:

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

Patient Signature: _________________ Date: _________ Physician Signature: ______________ Date: _________ Witness Signature: ________________ Date: _________