Compilation of Rules and Regulations of the State of Georgia
Department 360 - RULES OF GEORGIA COMPOSITE MEDICAL BOARD
Chapter 360-14 - INFORMED CONSENT
Exhibit (360-14) B
Current through Rules and Regulations filed through March 20, 2024
CONSENT TO SURGICAL OR DIAGNOSTIC PROCEDURES AND WAIVER OF RIGHT TO RECEIVE INFORMATION IN CONNECTION THEREWITH
DO NOT SIGN THIS FORM WITHOUT READING AND UNDERSTANDING ITS CONTENTS.
Name of Patient___________________________ Date___________
(A)
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(B) I acknowledge and understand and duly evidence in writing by executing this form that under Georgia law I am entitled to receive the following information relative to the procedure(s) described in paragraph (A):
(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 AND I FULLY AND COMPLETELY WAIVE THE RIGHT TO BE INFORMED OF THE INFORMATION SPECIFIED IN PARAGRAPH (B) AND REQUEST THAT SUCH INFORMATION NOT BE DISCLOSED.
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Witness
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Signature of patient or other person authorized to sign