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Medical/Surgical Treatment Consent Form (18+)

Consent For Treatment (18+)

  • DD dash MM dash YYYY
  • The doctors at the above-named hospital have recommended the following medical treatments
  • I consent to the medical treatments, procedure. I also consent to any further procedures which in the opinion of the doctor(s) performing the procedure, and any related medical treatments may be indicated due to any emergency that arises during the procedure. The operation or procedure will be performed by the doctor named below (or in the event he/she is unable to perform or complete the procedure, a qualified substitute doctor) I am aware that all operations and the procedure carries risks of unsuccessful results, complications, injury or even death from both known and unforeseen causes and no warranty or guarantee is made as to the result or cure. I have been informed of:
    • The nature of the operation or procedure, including care treatment and medications
    • Potential benefits, risks or side effects of the operation or procedure, including potential problems that might occur with the anesthesia to be used and during recuperation;
    • The likelihood of achieving treatment goals;
    • Alternative remedies and risks, benefits, and side effects related to such alternatives.
  • I am covered by the following insurance/HMO plan:
  • I affirm that I clearly understand the language of the presentation. The option to think over the procedure for a period before assenting was also presented to me.
  • DD dash MM dash YYYY

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