Informed Consent for Surgery

I First Name* Last Name* authorize (Name of Practitioner) authorize and any appropriate designees selected by my Practitioner, to perform the following surgery or special procedure(s) (the "Procedure"):

Name and Description of the Procedure (must be completed by Practitioner):*

RightLeftN/A

The following information has been discussed with me about the Procedure listed above:

The nature and intended purpose.The potential risks, benefits and side effects, including any possible duration of incapacity and potential problems that may occur during recovery from the Procedure.The reasonable alternatives, including the potential risks, benefits and side effects related to those alternatives.The risks and consequences of not receiving the Procedure.The possible or likely results of the Procedure, including my likelihood of achieving treatment goals.

I understand that during the course of the Procedure, unforeseen conditions may arise thatrequire additional or different procedure(s) other than the Procedure listed in Paragraph 1.

I authorize and request that my Practitioner and any appropriate designees perform such other procedures as necessary in the exercise of theirprofessional judgment.This authority extends to treating all conditions that are unknown to me at the time the Procedure is undertaken.

I understand that I may need a transfusion(s) of blood and/or blood products in connection with the Procedure. I have been given and have read the Patient Information Sheet on Blood Transfusions, and my Practitioner has discussed with me the following information about blood transfusions:

The reason(s) I may need a blood transfusion; the nature and intended purpose; the potential risks, benefits and side effects, including any potential problems that may occur during recovery from the transfusion(s); the reasonable alternatives, including the potential risks, benefits and side effects related to those alternatives; the possible options including autologous, homologous and directed donation; any possible duration of incapacity; the risks and consequences of not receiving a transfusion(s); and the possible or likely results of the transfusion(s), including my likelihood of achieving treatment goals.That a blood transfusion is not always successful and that no guarantee or assurance has been made to me or anyone concerning the benefits or results of a transfusion, and that I may be subject to ill effects as a result of receiving blood and/or blood products.That this consent applies to all transfusions I may receive related to the Procedure.

For blood transfusions, I have decided:

I CONSENT to receive blood and / or blood products

YesNo

If I DO NOT CONSENT to receive blood and blood products, I understand that my refusal to have a blood transfusion may cause serious illness and possible death.

I further understand that I will be offered registration int he Blood Alternative Program. (Patient Initial) (Patient must initial if refusing blood and blood products.)

I have been given and have read the Patient Information Sheet on Anesthesia and I consent to the administration and management of such anesthesia as the anesthesiologist assigned to my Procedure deems appropriate.I have also been given and have read the Patient Information Sheet on Moderate Sedation/Analgesia ("Conscious Sedation") and I understand that moderate sedation may be administered by a doctor other than an anesthesiologist, or by a nurse under the direction of a doctor, and I consent to the administration and management of such moderate sedation as the doctor deems appropriate.I have been informed of the risks most commonly associated with the administration of anesthesia and moderate sedation.I am aware that complications from all forms of anesthesia and moderate sedation are rare, but may occur.

I have been given and have read the Patient Information Sheet on the use of x-rays during my procedure.I consent to the administration of x-rays as my Practitioner deems appropriate.I have been informed of the risks most commonly associated with the exposure to radiation.

Informed Consent for Surgery or Special Procedures

1. Authorization

2. Surgery or Special Procedure

3. Additional Procedures

4. Blood Transfusions

5. Anesthesia

6. Radiation

7. Specimens

8. Vendors

9. Acknowledgement

Statement of Patient or Patient's Representative

Only if Patient is unable to consent, complete the following:

Statement of Practitioner Obtaining Consent: