Independence Orthopedics & Sports Medicine
Surgical Consent Form
The goal of orthopedic surgery is to relieve your pain and discomfort, improve
your function and enhance stability. We want you to be informed about the benefits and
risks of surgery.
Possible Complications
Blood Clots – Blood clots can be life threatening if they form in or travel to the lungs or
other vital organs. The staff may prescribe preventative measures to prevent such
complications, however even with multiple preventive measures blood clots can still
form.
Infection – With all surgeries, infection may occur. Pre-operative antibiotics may be
given, however the potential for infection always remains. The infection may occur
anytime during the post-operative period. Some infections can be treated with
antibiotics, but some deep / recurrent infections may require additional surgery and/or
admission to the hospital for IV antibiotics.
Anesthesia Reaction – Some patients have a negative reaction to anesthesia or pain
medication. If you have ever had a reaction during a previous surgery or treatment, be
sure to tell your doctor and your anesthesiologist.
Failure to Heal – Smokers, diabetics, rheumatoids, malnourished, and people with other
systemic diseases may be slow to heal or not heal at all. Failure to heal may result in
continued pain or subsequent surgeries.
Blood vessel, tendon, ligament, skin, or soft tissue damage – All of these structures
must be moved out of the way to perform orthopedic surgery. Scarring and damage can
occur.
Nerve Injury – Can result in areas of numbness and/or weakness. The damage may be
temporary or permanent.
Pain – Medication will be provided during the peri-operative period to adequately treat
your pain. In some cases preoperative pain does not improve. This could require further
treatment or surgery may be necessary.
Blood transfusions – May be necessary after surgery. Great caution is exercised by the
blood bank to ensure its safety, however in rare cases transmittable diseases can occur.
Patient wishes regarding blood transfusions will be honored and you must alert your
physician prior to surgery.
Metal Implants – Screws, plates, joint hardware, or rods, may be used in the surgery.
There is a greater risk of infection when a foreign object is in the body. There is the risk
of implant breakage or loosening and the possibility of re-operation to remove or replace
the implant.
Medical Problems – During the operation and post operative period, there is a greater
risk for medical problems. Including, but not limited to stroke, heart attack, pneumonia,
and possible exacerbation of any current medical problems.
Loss of Limb
Death
Physical, Emotional or Financial Hardship – May result as a consequence of any or all
of the above mentioned complications.
By signing this consent form you are stating that you have thoroughly read the
consent form and understand the risks involved in orthopedic surgery. I understand that I
have no guarantee of good results and no guarantee that complications will not occur. I
understand that if any of these complications are unacceptable to me that I may cancel the
surgery.
Patient
: ___________________________
Date: __________
Surgeon
: ___________________________
Date: __________