AUTHORIZATION FOR SURGERY
PATIENT _______________________________ AGE ________ DATE ______________
Admission Date __________________________
I authorize Dr._________________________ and whomever he may designate as his
Assistant(s) to perform upon ____________________________ the following operation(s):
(patient or myself)
The nature and purpose of the operation, the possible alternative methods of treatment, and the risks involved, have been fully explained to me. I understand that no guarantee has been made as to the results that will be obtained. I understand that all surgery is followed by the formation of a scar.
I understand that the risks and complications of any operation, including those secondary to the anesthesia, include even death; and the risks secondary to the surgery include major bleeding, infection, thromboembolism (blood clots), limited movement, persistent pain, abnormal swelling, and the possibility of injury to blood vessels or nerves.
I understand that during the course of any operation, that it may be necessary for the physicians to deviate from the originally planned procedures and I herein authorize the physicians to use their discretion as medically necessary.
I hereby authorize the administration of anesthesia by the physicians in the Department of Anesthesiology, or by Dr._____________________
and the use of such anesthetic agents, as they deem advisable.
I hereby authorize the hospital pathologist to use their discretion in the disposal of any tissue or specimen removed at surgery.
I hereby understand that it may be necessary during or after surgery to administer blood transfusions and that there are certain rare complications of transfusions including AIDS or
Hepatitis. The benefits, risk, and alternatives associated with the administration of blood or blood products have been explained to me by my physician.
I acknowledge that if surgical implants or devices are used or are necessary in the accomplishment of this surgery, that it may be necessary or recommended at a later time that such implants or devices be removed
I authorize the use of photography during surgery with a clear understanding that any recording of the surgical procedure would be used purely for the purposes of medical education and not for any other purpose whatsoever.
I have read and understand the above consent to Operative Treatment.
___________________________________
Patient/Parent/Guardian
___________________________________
Relationship to Patient
I have personally explained the above information to the patient.
___________________________________
Witness____________________________________
Physician:
Date____________________