Surgical Treatment Agreement and Informed Consent

Patient Information

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

Procedure Information

Proposed Surgery: __________________________________________ Side/Location: ____________________________________________ Surgeon: ________________________________________________

Agreement Sections

1. Consent to Surgical Procedure

I hereby authorize Dr. _________________ and such assistants as may be selected by them to perform the above-named surgical procedure.

2. Understanding of Procedure

I understand that the following will be done during the procedure:

• [Description of procedure to be inserted]
• Use of appropriate anesthesia as determined by the anesthesiologist
• Possible modification of the procedure as deemed necessary during surgery

3. Risks and Complications

I understand that any surgical procedure involves risks, including but not limited to:

• Bleeding
• Infection
• Adverse reaction to anesthesia
• Blood clots
• Scarring
• [Procedure-specific risks to be listed]

4. Alternative Treatments

I acknowledge that the following alternatives have been discussed with me:

• Conservative management
• Medical therapy
• [Other alternatives to be listed]

5. No Guarantee

I understand that no guarantee has been made regarding the outcome of this procedure.

6. Consent to Emergency Procedures

I authorize the performance of any additional procedures that may be deemed necessary in the event of a medical emergency during the procedure.

Signatures

Patient/Legal Guardian: _____________________ Date: _________

Witness: _________________________________ Date: _________

Surgeon: _________________________________ Date: _________

Interpreter (if applicable)

I have translated this consent form and related discussions to the patient or legal representative.

Interpreter: _______________________________ Date: _________