Wayne Memorial Hospital
INFORMED CONSENT TO SURGICAL PROCEDURE
It is very important to your doctor that you understand and consent to the treatment your
doctor is rendering and any surgery your doctor may perform. You should be involved in any and
all decisions concerning the surgical procedure. Sign this form only after you understand the
procedure, the risks, the alternatives, the risks associated with the alternatives, and all of your
questions have been answered. Please initial and date directly below this paragraph indicating
your understanding of this paragraph.
________________________________________ _______________________________
Patient's Initials or Authorized Representative Date
I, __________________________________, hereby authorize Dr. ______________________and
any associates or assistants the doctor deems appropriate, to perform (circle one: LEFT,
RIGHT, BOTH, UNILATERAL)_____________________________________________
_____________________________________________________________________________.
I consent to have _________________________________________ (name and title) perform the
following tasks (list): _____________________________________.
The risks and benefits associated with the procedure have been explained to me. However,
I understand there is no certainty that I will achieve these benefits and no guarantee has been made
to me regarding the outcome of the procedure(s). I also authorize the administration of sedation
and/or anesthesia as may be deemed advisable or necessary for my comfort, well being and safety.
The risks and possible undesirable consequences associated with the procedure have been
explained to me including, but not limited to, blood loss, transfusion reactions, infection, heart
complications, blood clots, loss of or loss of use of body part or other neurological injury or death.
Other risks may include:___________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
I understand that if I need blood or blood products these carry a risk of contracting HIV/AIDS,
Hepatitis, or reactions such as the symptoms of fever, chills, hives or in more severe reactions, the
destruction of the transfused red cells (Hemolytic Transfusion Reaction), antibody stimulation,
bacterial infections or, in rare situations, death.
!CO9030-02! Affix Patient Label
Informed Consent to Surgical Procedure, Side Two
In permitting my doctor to perform the procedure(s), I understand that unforeseen
conditions may be revealed that may necessitate change or extension of the original procedure(s)
or a different procedure(s) than those already explained to me. I therefore authorize and request
that the above-named physician, his assistants, or his designees perform such procedure(s) as
necessary and desirable in the exercise of his/her professional judgment.
The reasonable alternative(s) to the procedure(s) have been explained to me. These
alternatives include but are not limited to: __________________________________________
____________________________________________________________________________
I hereby authorize my doctor to utilize or dispose of removed tissues, parts or organs
resulting from the procedure(s) authorized above. I consent to any photographing or videotaping
of the procedure(s) that may be performed, provided my identity is not revealed by the pictures or
by descriptive texts accompanying them. I also consent to the admittance of students or authorized
equipment representatives to the procedure room for purposes of advancing medical education or
obtaining important product information. As required by the Safe Medical Device Act, I consent
to the release of my name, address, and social security number to the manufacturer of any medical
device I receive.
By signing below, I have had an opportunity to ask the doctor all questions
concerning risks, alternatives, and risks of those alternatives.
________ ________ ___________________________ _________________________
Date Time Signature of Patient or Relationship of Authorized
Authorized Representative Representative
The Patient/Authorized Representative has read this form or had it read to him/her.
The Patient/Authorized Representative states that he/she understands this
information
The Patient/Authorized Representative has no further questions.
_______________ _______________ ____________________________________
Date Time Signature of Witness
CERTIFICATION OF PHYSICIAN:
I hereby certify that the facts, risks, the risks associated with the alternatives of the
procedure(s) described in this form have been discussed with the individual granting consent.
_______________ _______________ ____________________________________
Date Time Signature of Physician
9030-02 R11/06, R03/07 J/FORMS /Consent-Informed/General online Affix Patient Label
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