Current through Rules and Regulations filed through March 20, 2024
DO NOT SIGN THIS FORM WITHOUT READING AND UNDERSTANDING ITS
CONTENTS
Name of Patient______________________ Date________________
(A)
(1) I acknowledge and understand that the
following procedure(s) which has (have) been described to me is (are) to be
performed on the patient:
__________________________________________________________
__________________________________________________________
__________________________________________________________ and that as a result
of the performance of the procedure(s) there is a material risk that the
patient may suffer infection, allergic reaction, severe loss of blood, loss or
loss of function of any limb or organ, paralysis or partial paralysis,
paraplegia or quadraplegia, disfiguring scar, brain damage, cardiac arrest, or
death.
(2) I acknowledge and
understand that during the course of the procedure(s) described in subparagraph
(A) (1) above, conditions may develop which may reasonably necessitate an
extension of the original procedure(s) or the performance of procedure(s) which
are unforeseen or not known to be needed at the time this consent is obtained.
I therefore consent to and authorize the persons described in the last
paragraph of this consent to make the decisions concerning the performance of
and to perform such procedure(s) as they may deem reasonably necessary or
desirable in the exercise of their professional judgment, including those
procedures that may be unforeseen or not known to be needed at the time this
consent is obtained. This consent shall also extend to the treatment of all
conditions which may arise during the course of such procedures including those
conditions which may be unknown or unforeseen at the time this consent is
obtained.
(B) I
acknowledge and understand and duly evidence in writing by executing this form
that I have been informed in general terms of the following:
(1) A diagnosis of the condition requiring
the procedure(s);
(2) The nature
and purpose of the procedure(s);
(3) The material risks of the procedure(s)
(see paragraph (A) above);
(4) The
likelihood of success of the procedure(s);
(5) The practical alternatives to such
procedure(s); and
(6) The prognosis
if the procedure(s) is (are) rejected; and that such was provided through the
use of video tapes, audio tapes, pamphlets, booklets, or other means of
communication or through conversations with the responsible physician, or other
medical personnel under the supervision and control of the responsible
physician, other medical personnel involved in the course of treatment, nurses,
physician's assistants, trained counselors, or patient educators.
(C) I acknowledge that there are
practical alternatives to the procedure(s) described in paragraph (A) which
alternatives reasonably prudent physicians generally recognize and
accept.
(D) I acknowledge and
understand that this request for and consent to surgical or diagnostic services
shall be valid for the responsible physician, all medical personnel under the
direct supervision and control of the responsible physician, and for all other
medical personnel otherwise involved in the course of treatment. I HAVE BEEN
GIVEN AMPLE OPPORTUNITY TO ASK QUESTIONS AND ANY QUESTIONS I HAVE ASKED HAVE
BEEN ANSWERED OR EXPLAINED IN A SATISFACTORY MANNER.
BY SIGNING BELOW, I ACKNOWLEDGE I HAVE READ OR HAD IT READ OR
EXPLAINED TO ME AND I UNDERSTAND THIS FORM AND I VOLUNTARILY CONSENT TO ALLOW
DR._____________ OR ANY PHYSICIAN DESIGNATED OR SELECTED BY HIM OR HER AND ALL
MEDICAL PERSONNEL UNDER THE DIRECT SUPERVISION AND CONTROL OF SUCH PHYSICIAN
AND ALL OTHER PERSONNEL WHICH MAY OTHERWISE BE INVOLVED IN PERFORMING SUCH
PROCEDURES TO PERFORM THE PROCEDURES DESCRIBED OR OTHERWISE REFERRED TO
HEREIN.
____________________
Witness
____________________________________
Signature of patient or other person authorized to
sign
