Self Assessment
Choose Consent Form
abdominoplasty surgery
File Number:
Consent to Medical / Surgical Procedure
I (or my authorized representative, i.e., parent guardian),
consent to the medical/surgical procedures outlined below to be performed by Dr.
and his staff, associates, or assistants to whom the physician(s) performing the procedure may assign designated responsibilities. The proposed medical/surgical procedure is
(Procedure) for the diagnosis/treatment of
(Diagnosis) . The procedure has been explained to me in terms that I understand. The explanation included:
• The nature and extent of the procedure to be performed.
• The most frequently occurring risks of the procedure involved, and those risks which are unlikely to occur but which may involve serious consequences, include but are not necessarily limited to the following:
• General risks which may include pain, scarring, Keloid formation, recurrence, non-healing wound, bleeding and infection.
• The benefits of the Procedure.
• The estimated period of incapacity or convalescence, if any.
• The risks and benefits of any reasonable alternatives to this procedure including having no treatment at all.
• I confirm that I have chosen this procedure to be done by the above physician willingly and voluntarily.
• If any unforeseen condition arises during this procedure which requires transportation to a hospital, additional procedures, operation or medication including anesthesia and blood transfusions, I further request and authorize my physician to do whatever he deems advisable on my behalf and I confirm that I have agreed to pay for these services.
• 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 concerning the results of this procedure. No refunds will be provided for any services and that no other party other than I am held responsible for the services or treatments of any complications.
• I authorize that a physician in training may participate in my care; a representative or technician from a medical device company may be present at the procedure , medical photography may be utilized for medical , scientific, or educational purposes, provided my identity is not revealed in the photo or text.
• I was given the opportunity to ask any questions I have regarding the procedure and I have had those questions answered to my satisfaction. I acknowledge that I have read (or had read to me) and fully understand the above information. Furthermore, I certify that all my questions and concerns regarding the procedure , its attendant risks,benefits and alternative have been explained to my satisfaction. I hereby authorize my physician to perform the above discussed procedure.
Patient Name
Patient Signature
Date & Time
Parent or Guardian (if patient is minor)
Witness
Patient Signature
Print
