CONSENT TO SURGERY
(NOTE: PLEASE READ THIS FORM CAREFULLY AND COMPLETELY BEFORE SIGNING)
Patient: _______________________________________________
Address: ______________________________________________
I _________________________ hereby authorize DR R. THIND and such assistants as may be selected by the above mentioned, to perform the operation and / or procedure known as:
______________________________________________________.
The nature, potential complications, potential benefits and risk of this procedure as well as the possibility of alternative forms of therapy, have been explained to me by the physician so that I may make an informed decision.
I understand that any medical procedure carries risks. I have understood the risks with this particular procedure
______________________________________________________
I understand that although uncommon and unrelated to negligence, complications may occur.
I understand that it would be impractical and probably misleading to list every possible complication of the procedure mentioned above.
However, I acknowledge that the doctor is available to answer any questions that I might have concerning the above-mentioned procedure. I also acknowledge that no guarantee or assurance has been made to me as to the results that may be obtained. Risks involved such as infection, bleeding, scarring, adhesions, and others may occur.
I hereby grant DR R. THIND permission to photograph / film / videotape me before, during and after the above-mentioned procedure. I understand that the photographs / film / videotape are the property of the photographer.
I consent to the sending of tissue samples removed to an outside laboratory for histological examination if deemed by so DR R. THIND.
I also specifically authorize the above named physician or his assistants, to perform such additional procedures or render such treatment as deemed necessary in his professional judgment in the event that any unforeseen condition arises which would jeopardize my health during the course of, or after, the consented operation.
I certify that I have read and fully understood the above form, that the explanations therein referred to were made and that all blanks or statements requiring insertion or completion were filled in and inapplicable paragraphs, if any were stricken before I signed.
I GIVE MY CONSENT TO HAVE THE ABOVE MENTIONED PROCEDURE(S) PERFORMED UNDER THE ABOVE MENTIONED CONDITIONS.
SIGNATURE OF PATIENT: __________________________________________
SIGNATURE OF WITNESS: _________________________________________
DATE / MONTH / YEAR: ____________________________________________
SIGNATURE OF PHYSICIAN:
_________________________________________
REQUEST FOR SURGICAL SERVICES AND INFORMED CONSENT
Patient’s Name: __________________________________________________
Address: ________________________________________________________
To The Patient: You have the right to be informed about your condition and its treatment so that you may make the decision whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give or withhold your consent for treatment.
I voluntarily request my physician, Dr. Thind and such associates, technical assistants and other health care providers he may deem necessary, to treat my condition. The procedure has been explained to me as _______________________________________________
I understand that my physician can discover other or different conditions which require additional or different procedures than those planned. I authorize my physician, and such associates, technical assistant and other health care providers to perform other procedures that are advisable in their professional judgment.
Initial if you understand and agree ___________
I understand that no warranty or guarantee has been made to me as to result or cure. Realistic expectations are 50 to 75% improvements. Some patients have great improvement and some have no appreciable improvement.
Initial if you understand and agree ___________
Just as there are risks and hazards of continuing my present condition without treatment, there are also risks and hazards to the performance of the surgical, medical and/or diagnostic procedure is the potential for infection, allergic reactions, bruising, bleeding, hematoma formation or blindness. I also realize that the following risks and hazards may occur in connection with the particular procedure: 1) worsening or unsatisfactory appearance, 2) creation of additional problems such as: a) poor healing or skin loss, b) nerve damage, c) painful or unattractive scarring, keloid formation or permanent skin pigment change or 3) recurrence of the original condition..
Initial if you understand and agree ___________
All possible alternatives for treatment with advantages and disadvantages have been explained to me in detail.
Initial if you understand and agree ___________
I have also discussed with the surgeon all the common risks / complications of the operation.
Initial if you understand and agree ___________
The following have also been carried out.
1) I have met the surgeon.
2) I have discussed the technique the surgeon will use for my operation.
3) I know where the theatre is.
4) I know how long the operation is going to take.
5) I know the cost of the operation and mode of payment.
6) I know all fees for surgery has to be paid before the surgery and the deposit paid is not refundable.
7) I know when I can return to normal activity after operation.
Initial if you understand and agree ___________
Dizziness may occur during the first week following surgery, particularly upon rising from a lying or sitting position. If this occurs, extreme caution must be exercised while standing. Someone must be present when you shower during the early post-operative period. Do not attempt to walk if dizziness is present.
Initial if you understand and agree ___________ I understand that secondary revisions or additional surgeries may be required in some cases. The cost of any of these additional surgeries is one-half the original surgeon’s fee. I understand that I will also be required to pay the additional anesthesia and operating room fees.
Initial if you understand and agree ___________
I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me as to the results of the operation or procedures nor are there any guarantees against an unfavorable result. I acknowledge that you will do your best for me but I also recognize that you lack infallibility and that mistakes and accidents can occur in medicine as they can in any discipline. In the absence of a deliberate, premeditated act of negligence, I will not sue you.
Initial if you understand and agree ___________
If I am a smoker, I accept the risk of respiratory complications and delayed wound healing resulting from the habit.
I have received a thorough explanation of my preoperative and postoperative instructions. I understand these instructions and have received copies for reference. I understand that should I have any questions about the preoperative or postoperative instructions I should not hesitate to call. I acknowledge my obligation to follow these instructions closely and to visit the clinic for follow up care and instructions on postoperative day one, five and ten.
Initial if you understand and agree ___________ I certify that I have read the above consent and I fully understand it. I have been given ample opportunity for discussion and all my questions have been answered to my satisfaction. I have received no medication before signing this consent. I hereby consent to surgery. This constitutes the full disclosure and supersedes any previous verbal or written disclosures.
NOTE: SINCE SMOKERS HAVE A HIGHER RATE OF RESPIRATORY COMPLICATIONS AND DELAYED WOUND HEALING, SMOKING IS NOT RECOMMENDED BEFORE OR AFTER SURGERY.
Witness Signature: __________________________________________
Patient’s Signature: _________________________________________
Date & Time: ______________________________________________
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