CONSENT FOR PROCEDURE
(Patient Name or Name of the Patient's Authorized Legal Guardian/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 SHOULD BE USED)
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
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Significant Tasks
Consent for Procedure
/
Patient Name
DOB
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.
Physician or Practitioner :
Date:
Time:
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.
______________________________________________________________________________________
Signature of Patient, Legal Guardian or Authorized Representative
Date: ___________ Time: ____________
______________________________________________________________________________________
Signature of Witness to Consent
Date: ___________ Time: ____________
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 AIDS. 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
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Consent for Procedure
/
Patient Name
DOB
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 AIDS 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
________________________________
Signature of Interpreter
__________________________________
Relationship to Patient
________________________________
Print Interpreter’s Name
__________________________________
Relationship to Patient
________________________________
Signature of Interpreter
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