Neurosurgical Procedure Informed Consent Form

Patient Information

• Patient Name: _________________________
• Date of Birth: _________________________
• Medical Record Number: _________________

Procedure Details

I hereby authorize Dr. _________________ and/or associates to perform the following procedure:

Diagnosis and Purpose

The diagnosis and purpose of the procedure has been explained as:

Understanding and Acknowledgment

Nature of Procedure

I understand that the procedure involves (describe specific details):

• Location of surgical intervention
• Type of approach to be used
• Expected surgical steps

Risks and Complications

I acknowledge the following potential risks have been explained to me:

1. Common Risks

   • Post-operative pain and discomfort
   • Infection
   • Bleeding
   • Scarring

2. Specific Neurological Risks

   • Temporary or permanent neurological deficit
   • Paralysis
   • Speech difficulties
   • Memory changes
   • Seizures
   • CSF leak

Alternative Treatments

I understand the following alternatives have been discussed:

1. Conservative management
2. Medical therapy
3. Alternative surgical approaches
4. No treatment

Consent Declaration

I confirm that:

• All my questions have been answered satisfactorily
• I understand the risks and benefits
• I have had sufficient time to make this decision
• I consent to photography/videography for medical documentation

Signatures

Patient/Guardian: _________________ Date: _________

Witness: _________________________ Date: _________

Surgeon: _________________________ Date: _________