Orthopedic Surgery Informed Consent Form

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record #: ______________ Date: _____________________

Procedure Information

Proposed Surgery: __________________________________________ Side/Location: □ Right □ Left □ Bilateral □ Other: ____________

Surgeon Declaration

I, Dr. _________________, have explained to the patient:

• The nature of their orthopedic condition
• The proposed surgical procedure
• Alternative treatment options
• Expected benefits and potential risks

Risks and Complications

I understand the following risks have been explained to me:

Common Risks (>1%)

• Post-operative pain and discomfort
• Scarring
• Bleeding
• Infection
• Stiffness and reduced range of motion

Less Common Risks (0.1-1%)

• Blood clots (DVT/PE)
• Nerve injury
• Hardware complications
• Delayed healing

Rare Risks (<0.1%)

• Severe allergic reactions
• Complex regional pain syndrome
• Need for additional surgery

Patient Acknowledgment

I confirm that:

• I have read and understand this form
• My questions have been answered satisfactorily
• I understand the risks and benefits
• I agree to the proposed procedure

Signatures

Patient/Guardian: _________________ Date: _________ Time: _____ Surgeon: ________________________ Date: _________ Time: _____ Witness: ________________________ Date: _________ Time: _____

Interpreter (if applicable)

Name: ___________________________ Date: _________ Time: _____