Vascular Surgery Treatment Consent and Agreement

Patient Information

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

1. Consent for Treatment

I, _________________________, hereby authorize Dr. _________________ and associates to perform vascular surgical procedures and related treatments as deemed necessary for my medical condition.

2. Nature of Proposed Treatment

Procedure(s): _________________________________________________ Diagnosis: ____________________________________________________

3. Risks and Complications

I understand that known risks of vascular surgery include but are not limited to:

• Bleeding or hemorrhage
• Infection at the surgical site
• Blood clots (thrombosis)
• Vessel damage or occlusion
• Nerve injury
• Tissue death (necrosis)
• Amputation (in severe cases)
• Complications from anesthesia
• Death (in rare cases)

4. Alternative Treatments

I acknowledge that alternative treatment options have been explained to me, including:

• Conservative medical management
• Endovascular procedures
• No treatment

5. Financial Agreement

I understand that I am responsible for:

• Insurance copayments and deductibles
• Charges not covered by insurance
• Obtaining necessary pre-authorizations

6. Follow-up Care

I agree to:

• Attend all scheduled follow-up appointments
• Follow post-operative instructions
• Report any concerning symptoms promptly
• Comply with medication regimens

Signatures

Patient/Legal Guardian: _________________________ Date: __________

Witness: _____________________________________ Date: __________

Physician: ____________________________________ Date: __________