Summit Medical Group
Ambulatory Surgery Center
Patient Label
Consent for Procedure / Treatment
To the Patient: You have been given information about your condition and the recommended surgical, medical, dental, or diagnostic
procedure(s) to be used. This consent form is designed to provide a written confirmation of such discussions by recording some of
the more significant medical information given to you. It is intended to make you better informed so that you may give or withhold
your consent to the proposed procedure(s).
1.
Condition
Dr. Momeni / Dr. Hyans has explained to me that I have the following medical/dental condition:
(Explain in lay terms): Gynecomastia
____________________________________________________________________________________
2.
Proposed Operation
I understand that the operation / procedure(s) proposed for evaluating and treating my condition is(are):
Gynecomastia surgery with Excision & Liposuction Excision only Liposuction only.
________________________________________________________________________________
For
Side / Digit /
Spine Level
Only
For Sided or Finger Surgery Only. Must be completed Day of Surgery prior to procedure.
1. Patient, procedure, site verification has taken place _____________ Yes.
2. Correct side/digit/spine level has been indelibly marked ___________ Yes.
3. Surgeon must attest by signature and date that the above has taken place.
SIGNATURE _______________________________________________ DATE ____/_____/______
3.
Risks / Benefits of
Proposed
Procedure(s):
Just as there may be benefits to the procedure(s) proposed. I also understand that surgical and medical
procedures as well as the giving of anesthetic agents involve risks. Standard risks include allergic
reactions, bleeding, blood clots, infections, adverse side effects of drugs, and even loss of bodily
function or life. Other risks include: Bruising, swelling, scarring, delayed healing, and/or need for
further surgery.
4.
Complications,
Unforeseen
Conditions, Results
I am aware that in the practice of medicine and surgery, other unexpected risks or complications not
discussed may occur. I also understand that during the course of the proposed procedure(s), unforeseen
conditions may be revealed requiring the performance of additional procedures, and I authorize such
procedures to be performed. I further acknowledge that no guarantees or promises have been made to me
concerning the results of any procedure or treatment.
5.
Acknowledgement
I understand that some of the available alternatives include: NO SURGERY
.
_____________________________________________________________________________________
_____________________________________________________________________________________
The potential benefits and risks of the procedure(s), the above alternatives and the likely result without
such treatments have been explained to me. I understand what has been discussed with me as well as the
content of this consent form, and have been given the opportunity to ask questions and have received
satisfactory answers.
Having read this form and talked with my physicians, my signature below acknowledges that I voluntarily
give my authorization and consent to the performance of the procedure(s) described above (including
disposal of tissue) by my physician and/or such assistants as may be selected by him/her.
6. Consent to:
 _________________________________________ _________________________ Date: __/___/___
Patient (or Person Authorized to Sign for Patient)
Relationship to Patient
 _________________________________________ _________________________ Date: __/___/___
Physician / Surgeon
Witness