ALBERT EINSTEIN HEALTHCARE NETWORK

CONSENT FOR OPERATION AND RENDERING

OTHER MEDICAL SERVICES

Patient Label (Name and Medical Record #) AEMC/MREP

  1. I ______(patient) hereby authorize Dr. ______(supervising physician or surgeon) and such other physicians as he/she may delegate or deems necessary or advisable, to perform the following procedure:

Roux en Y Gastric Bypass

for the treatment of obesity.

The nature and purpose of the treatment/procedure(s) and moderate sedation/local or regional anesthesia; possible alternative methods of diagnosis, treatment and moderate sedation/local or regional anesthesia; the risks of the treatment/procedure(s) and of the alternatives; the possibility of complications; the foreseeable consequences of the treatment/procedure(s), potential problems relating to recuperation; the likelihood of achieving the care, treatment and service goals; and the possible results of non-treatment have been explained to me. I have read the accompanying consent materials regarding the risks and have been given the opportunity to discuss and ask any questions of the attending surgeon. I acknowledge that no guarantee or assurance has been made as to the results that may be obtained.

I understand that this procedure may have to be converted to an “open” approach for such reasons which include, but are not limited to: significant bleeding, extreme obesity, large liver size, severe scar tissue and equipment malfunction. No guarantee or assurance that my surgery will be completed laparoscopically has been made to me.

  1. As has been explained to me, AEMC is a teaching hospital where fellow(s), resident(s), and/or physician assistant(s) may participate in the surgical procedure(s) including performing significant surgical tasks, by assisting the attending physician under his/her supervision. Practitioners conducting significant surgical tasks will be identified in the patient’s post-operative surgical note. Therefore, I consent specifically that fellow(s), resident(s), and/or physician assistant(s) may participate in part of the medical or surgical procedure(s), including performing significant surgical tasks, as authorized and supervised by the attending physician(s) as named above. I also understand that the fellows(s), resident(s) or physician assistant(s) who may be scheduled to participate in the procedure may change prior to the time of the procedure.
  1. I authorize the following device(s) to be implanted during the above-named procedure: (type of device/implant)

______

  1. I authorize the above named physician to administer local, regional anesthesia, or moderate sedation (for all other anesthesia management, a separate consent must be signed by the patient or patient’s authorized representative).
  1. I understand that if it is necessary for me to receive a blood transfusion during this procedure or immediate post-operative period, the blood will be supplied by sources available to the hospital and tested in accordance with national and regional regulations. I understand that there are risks in transfusion, including but not limited to allergic, febrile, and hemolytic transfusion reaction, and the transmission of infectious agents such as hepatitis and/or HIV (Human Immunodeficiency Virus). Careful donor selection and available laboratory tests do not eliminate the hazard. I hereby consent to blood transfusion(s) and/or blood derivative(s).
  1. I have been informed that students and/or manufacturer’s representatives may be present during the above-named procedure for educational purposes or to provide technical support for the equipment that may be used during this procedure.
  1. I hereby authorize representatives from Einstein to photograph or videotape my surgery for the purpose of research or medical education. It is understood and agreed that patient confidentiality shall be preserved (no identifying information will be used).
  1. I authorize the physician named above and/or his/her associates and assistants and Albert Einstein Medical Center to preserve for scientific purposes, or to dispose of any tissue, organs, or other body parts removed during surgery or other diagnostic procedures in accordance with customary medical practice.
  1. I certify that I have read and fully understand the above consent statement and the accompanying consent materials. The procedure to be performed was explained to me and I have had sufficient opportunity to ask whatever questions I might have and they have been answered to my satisfaction and full understanding. I voluntarily and freely consent to the proposed procedure.

______

Patient Signature Date and Time

______

Witness to signature only

If the patient is unable to give informed consent on his/her own behalf, complete the following:

______is unable to consent because______

Patient

______

Legally Responsible Person Relationship to Patient Witness

I certify that I have explained the procedure(s) and the information set forth above and in the attached materials to the patient or patient’s authorized representative.

______

Name and Signature of Physician who explained the procedure Date and Time

to the patient or authorized representative

Attending Fellow Resident

Surgeon’s Verification (to be signed in operative suite):

Patient Name ______

Operative Site (include side) ______

Verified by ______Date ______Time ______

(Physician’s Signature)