AUTHORIZATION FOR MEDICAL TREATMENT, ANESTHESIA AND PERFORMANCE OF
OPERATION 

I hereby authorized ________________________ and associates and
assistants as  designated by ________________________ to perform
the following medical procedure: 

________________________________________________________________

It has been explained to me that during the course of the 
operation or procedure, unforeseen conditions may be revealed or 
encountered that necessitate surgical or other procedures in 
addition to or different from those contemplated, I further 
require and authorize ________________________, associates and
assistants, to perform  additional procedures as they may deem
immediately necessary. 

I consent to administration of anesthesia and to the use of such 
anesthetic as may be deemed necessary. 

I further consent to the administration of such drugs, infusions, 
plasma or bloods transfusion deemed necessary in the judgment of 
________________________, and associates and assistants as
designated by ________________________. 

I further consent to the examination for anatomical purposes and 
disposal by authorities of the hospital of any bodily tissues and 
parts that may be removed during the procedure. 

I also consent to photographing, videotaping, or closed circuit 
televising, and the publication regarding the operations(s) or 
procedure(s) to be performed provided my identity is not revealed 
and that the use is limited to medical, scientific or educational 
purposes. I waive all rights that I may have to any claims for 
payment in connection with the exhibition of the recordings. 

The nature and purpose of the procedure, its necessity, and 
possible alternative methods of treatment, the risks involved, 
and the possibility of complication in the treatment of my 
condition have been fully explained to me, and I understand them. 
I recognize that the practice of medicine and surgery is not an 
exact science, and I acknowledge that no guarantees or assurances 
have been made to me concerning the results of this procedure. 


***** READ CAREFULLY ***** 

***** DO NOT SIGN WITHOUT READING CAREFULLY ***** 

Dated: ___________________ 


Time of signature: ___________ 





______________________________________ 


Witness: 



______________________________________