Vascular Surgery Informed Consent Form

Patient Information

Name: _________________________ Date of Birth: __________________ Medical Record #: _______________

Proposed Procedure

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

Nature of the Procedure

Description

• The procedure involves: [specific details to be filled]
• Location of surgery: _______________
• Expected duration: ________________

Risks and Complications

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

Common Risks (>1%)

• Bleeding or bruising
• Infection at surgical site
• Pain or discomfort
• Scarring
• Blood clots

Serious Risks (<1%)

• Vessel damage or occlusion
• Nerve injury
• Need for emergency surgery
• Limb loss (in extreme cases)
• Cardiovascular complications

Alternative Treatments

I understand the following alternatives have been discussed:

1. Conservative management
2. Medical therapy
3. Other surgical approaches
4. 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 have been informed about recovery expectations

Signatures

Patient/Guardian: _________________ Date: _______ Physician: _______________________ Date: _______ Witness: _________________________ Date: _______

Emergency Contact

Name: ___________________________ Phone: __________________________