CONSENT FOR PROCEDURE
_______________________________ / ___________(Patient Name / Patient Date of Birth) hereby
authorize Dr._________________________ and/or such assistants as may be selected by him/her to
perform the following operation/procedure: (NOTE: NO ABBREVIATIONS/ACRONYMS)
__________________________________________________________________________________
__________________________________________________________________________________
BENEFITS AND ALTERNATIVES OF PROPOSED OPERATION/PROCEDURE
Dr. _____________________ has discussed with me the reasons, anticipated benefits for this
operation/procedure, the probability of its success and the possible consequences of not having this
operation/procedure which includes _____________________________________________________
__________________________________________________________________________________
In addition, I understand my condition could be treated by alternative procedures or therapies such as
_______________________________________________________________________but have
decided not to undergo these alternative treatments at this time.
RISKS OF PROPOSED OPERATION/PROCEDURE
This authorization is given with the understanding that the practice of medicine and surgery is not an
exact science and no guarantees have been made to me by anyone as to the results of the
operation/procedure. I further understand that any operation or procedure and recuperation involve
some risks and hazards. The more common risks include infection, bleeding, nerve injury, blood clots,
heart attack, allergic reactions, severe blood loss, and risks of blood transfusion (see Blood
Transfusion /Allograft Consent). These risks can be serious and possibly fatal. I have been made
aware of common risks associated with this particular operation/procedure that include but are not
limited to _________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
I recognize that during the course of treatment(s) or procedures(s), unforeseen conditions may
necessitate additional or different procedures or treatments than those set forth above. I, therefore,
further authorize and request that my physician and the appropriate staff perform such procedures or
treatments as are deemed necessary.
SURGICAL TASKS
I understand that some aspects of the surgical procedure or significant surgical tasks (harvesting
grafts, dissecting tissue, removing tissue, implanting devices, altering tissue) may be performed by an
assistant(s) other than the primary surgeon/practitioner identified in this consent. I further understand
and consent to one or more of the assistants (Assisting surgeon, surgical assistants, and other health
care providers, residents/students), who may assist or perform one or more of the significant surgical
tasks referenced above. My surgeon has identified the assistant’s title and his/her role in the surgical
procedure if known at this time. If the names/roles of these practitioners are not known at this time, it
will be noted in the medical record.
Assistant(s) Title
Page 1 of 3
Consent for Procedure
DTM0008
Significant Tasks
___________________________________
Patient Name
_________________
Date of Birth
NAME OF FACILITY FOR PROCEDURE
 Saint Elizabeth Regional Medical Center BryanLGH Medical Center
 Nebraska Surgery Center Nebraska Heart Hospital Lincoln Surgical Hospital
Other_____________________________________________________________
PHYSICIAN/PRACTITIONER DECLARATION
I have explained the contents of this document to the patient including the risks, benefits and
alternatives. I have provided information to the patient and I have answered all the patient’s questions
and, to the best of my knowledge, the patient has been adequately informed and has consented to this
operation or procedure.
_____________________________________
Date: _____________ Time: ____________
Physician or Practitioner
PATIENT CONSENT
I acknowledge that I have had the opportunity to discuss my condition, proposed treatment, concerns
or questions with my physician/practitioner, including risks, benefits and alternative treatments. I
believe I have been given enough information, have had my questions answered, have adequate
knowledge to make an informed decision and wish to proceed with the proposed treatment/procedure.
I have read and understand this form and I voluntarily authorize and consent to the operation or
procedure.
________________________________________________ Date: _____________ Time: __________
Signature of Patient, Legal Guardian or Authorized Representative
________________________________________________ Date: _____________ Time: __________
Witness to the Signature of the Consent
IMPLANTS AND DEVICES IMPLANTED DURING THE OPERATION/PROCEDURE
I am aware that some surgical procedures require the implantation of medical devices and the federal
laws and regulations require manufacturers to track these devices. If applicable to this procedure, I
understand the physician and/or medical facility will release my Patient Health Information to the
appropriate device manufacturer(s) per State and/or Federal regulations.
TISSUE DISPOSAL
If any tissue, part, limb, or organ is removed, the medical facility will dispose of it in accordance with
the medical facilities usual custom.
 ALLOGRAFT CONSENT (CHECK IF APPLICABLE: consent signature must be completed)
Use of donated bone or tissue products if applicable, has been explained to me and I understand
that there are risks associated with implanting these types of products. These risks including
reactions to the bone/tissue, infections such as hepatitis and HIV. These risks can be serious and
possibly fatal. Alternative benefits of probability of success for using allograft have been
explained to me.
 I CONSENT to use of donated bone/tissue if determined necessary by my physician
______________________________________________________
Signature of Patient, Legal Guardian or Authorized Representative
 I DO NOT CONSENT to use of donated bone/tissue
______________________________________________________
Signature of Patient, Legal Guardian or Authorized Representative
Page 2 of 3
Consent for Procedure
___________________________________
Patient Name
_________________
Date of Birth
 BLOOD TRANSFUSION (CHECK IF APPLICABLE: consent signature must be
completed) Use of blood products (donated, banked or autologous) if applicable, has been
explained to me and I understand that there are risks associated with transfusion of blood or
blood products. These risks include serious reactions (allergic and other reactions), damage to
my own blood cells, infections such as hepatitis and HIV which are estimated to be less than
one in a million transfusions. These risks can be serious and possibly fatal. Alternatives to
blood transfusions have been explained to me. Additional options for my specific procedure
include pre-donation of my own blood (autologous blood donation), or the use of cell saver
during surgery. These options have been explained to me including the risks and benefits. I
understand that if I refuse blood or blood products (donated, autologous or use of cell saver),
the risks may include organ damage from inadequate oxygen supply, inability to control
bleeding, and sometimes even death.
 I CONSENT to blood transfusion if determined necessary by my physician
_____________________________________________________
Signature of Patient, Legal Guardian or Authorized Representative
 I DO NOT CONSENT to blood transfusion.
_____________________________________________________
Signature of Patient, Legal Guardian or Authorized Representative
 INTERPRETER DECLARATION(CHECK IF APPLICABLE: consent signature must be
completed)
This form, as completed above, was read in my presence to the patient or to the patient’s
representative. I interpreted the form for the patient or patient’s representative
_____________________________________________language as it was read.
___________________________________
Print Interpreter’s Name
_________________________________
Relationship to Patient
___________________________________
Signature of Interpreter
___________________________________
Print Interpreter’s Name
_________________________________
Relationship to Patient
___________________________________
Signature of Interpreter
Page 3 of 3
Consent for Procedure
___________________________________
Patient Name
_________________
Date of Birth