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Complete Home & Office Legal Guide
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Complete Home and Office Legal Guide (Chestnut) (1993).ISO
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1993-08-01
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AUTHORIZATION FOR MEDICAL TREATMENT, ANESTHESIA AND PERFORMANCE
OF OPERATION
I, as __________________ of ___________________ hereby authorize
____________________ 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 in ___________________ 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.
This consent is given by ___________________ due to the inability of
___________________ to give consent because:
_____________________________________________________________
***** READ CAREFULLY *****
***** DO NOT SIGN WITHOUT READING CAREFULLY *****
Dated: ___________________
Time of signature: ___________
______________________________________
___________________
Witness:
______________________________________