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Consent forProcedure / Treatment

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Patient Label

To the Patient: You have been given information about your condition and the recommended surgical, medical, dental, or diagnostic procedure(s) to be used. This consent form is designed to provide a written confirmation of such discussions by recording some of the more significant medical information given to you. It is intended to make you better informed so that you may give or withhold your consent to the proposed procedure(s).
  1. Condition
/ Dr. Momeni has explained to me that I have the following medical/dental condition:
(Explain in lay terms): ______
______
  1. Proposed Operation
/ I understand that the operation / procedure(s) proposed for evaluating and treating my condition is(are):
______
______

For

Side / Digit /
Spine Level
Only / For Sided or Finger Surgery Only. Must be completed Day of Surgery prior to procedure.
  1. Patient, procedure, site verification has taken place ______Yes.
  2. Correct side/digit/spine level has been indelibly marked ______Yes.
  3. Surgeon must attest by signature and date that the above has taken place.
SIGNATURE ______DATE ____/_____/______
  1. Risks / Benefits of Proposed Procedure(s):
/ Just as there may be benefits to the procedure(s) proposed. I also understand that surgical and medical procedures as well as the administration of anesthetic agents involve risks. These risks include allergic reactions, bleeding, blood clots, infections, adverse side effects of drugs, and even loss of bodily function or life. Other risks include:
______
______
  1. Complications, Unforeseen Conditions, Results
/ I am aware that in the practice of medicine and surgery, other unexpected risks or complications not discussed may occur. I also understand that during the course of the proposed procedure(s), unforeseen conditions may be revealed requiring the performance of additional procedures, and I authorize such procedures to be performed. I further acknowledge that no guarantees or promises have been made to me concerning the results of any procedure or treatment.
  1. Acknowledgement
/ I understand that some of the available alternatives include: NO SURGERY .______
______
The potential benefits and risks of the procedure(s), the above alternatives and the likely result without such treatments have been explained to me. I understand what has been discussed with me as well as the content of this consent form, and have been given the opportunity to ask questions and have received satisfactory answers.
6. Consent to: / Having read this form and talked with my physicians, my signature below acknowledges that I voluntarily give my authorization and consent to the performance of the procedure(s) described above (including disposal of tissue) by my physician and/or such assistants as may be selected by him/her.
 ______Date: __/___/___
Patient (or Person Authorized to Sign for Patient) Relationship to Patient
 ______Date: __/___/___
Physician / Surgeon Witness