Taoyuan Armed Forces General Hospital
Name：
Sex：
MRN#：
LETTER OF CONSENT FOR SURGERY
Age：
Attending physician performing the surgery：
1. Planned surgery (If the medical terms are not clear, please add a concise explanation.)
A. Diagnosis：
B. The recommended surgery：
C. Reasons for recommending this surgery：
(2) Physician’s declaration
A. I have done my best to explain the related information about the surgery in the way that could be easily
understood by my patient, especially the following subjects：
□The reasons, procedure, scope, risk, rate of success of the surgery and the possibility of blood transfusion.
□The complications which may occur during surgery and the possible treatment.
□The possible outcomes of not performing surgery and other alternatives.
□The temporary or permanent symptoms which may occur after surgery.
□As to the other related information about this surgery, I have already informed my patient.
B. I have given the patient enough time to ask the following questions about this surgery, and have explained
to him/her as best as I could：
（1）﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍
（2）﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍
（3）﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍
Signed by the attending physician：
Time：
17-G0-01A（This table has been approved by the Medical Record Management Committee, Oct. 1996, and was revised
in Sep. 2003.）
(3) Patient’s Declaration
1.
The physician has explained this surgery to me, and I fully understand the related information about the
necessity, procedure, risk, and rate of success of this surgery.
2.
The physician has explained this surgery to me, and I fully understand the advantage and risk of other
treatments.
3.
The physician has explained this surgery to me, and I fully understand the possible conditions after surgery and
the risk of not performing this surgery.
4.
I fully understand that I may have to transfuse blood during this surgery. □I agree □I don’t agree to
transfuse blood.
5.
I can ask my physician about my conditions, the procedure of surgery, the treatment, etc. and receive the
proper answers from him.
6.
I fully understand that if it is necessary to cut or remove some organs or tissues during surgery, the hospital
may keep them for a period of time in order to make some examination reports, and will treat them properly
according to the regulations of related laws afterward.
7.
I fully understand that this surgery may be the most appropriate choice at this time, but it does not mean that it
will completely improve my present conditions.
Based on the above-mentioned declarations, I have agreed to undergo this surgery.
Patient’s Relative
Signed by：
Address：
Tele No.：
Time：
----------------------------------------------------------------------------------------------------------------------------------------------Witness：
Time：
Remarks：
1. The risk of general surgery
(1) A small part of the lung may collapse and lose its function, which may increase the probability of causing
infection in the thoracic cavity. When this happens, antibiotics and respiration therapy may be needed.
(2) It may cause an embolism in the leg with pain and swelling. The coagulated clot may scatter into the lung
and may be fatal. But this situation is not common.
(3) Due to pressure on the heart, it may cause an incidence of heart disease or even cause heart paralysis.
(4) The medical institution and the medical experts will do their best to perform this surgery and treatment for
their patient, but this surgery is not always successful. Any accident may happen occasionally, and some
may even be fatal.
2. If this letter of consent is not signed by the patient himself/herself, the Column of「Patients Relative」shall be filled
out exactly.
3. If there is no witness, there is no need to fill out the witness column.
17-G0-01A（This table has been approved by the Medical Record Management Committee in Oct. 1996, and revised in Sep. 2003.）