Surgical Consent Form

1) I hereby request and authorize David T. Braun, MD, Daniel Perez-Musteller, DPM and whomever they may designate as assistants, to perform upon myself the following operation:

The operation is to include whatever procedures are required in attempting to accomplish such a purpose. If any conditions are revealed at the time of the operation that were not recognized before and which all for procedures in addition to the originally contemplated, I authorize the performance of such procedure.

2) The nature and purpose of the operation possible alternative methods of treatment, the risks involved, and the possibility of complications have been fully explained to me. Specific risks include, but are not limited to the risk of anesthesia, including death, cardiopulmonary problems, cerebrovascular problems, or other risks associated with allergies or reaction to anesthesia, bleeding, infection, damage to nerves or blood vessels, post operative pain, persistent disability, failure to achiever surgical goals, failure to heal, instability and dislocation, any unforeseen complications or need for additional procedure.I acknowledge that no warranty, guarantee or assurance has been made as to the results that may be obtained.

3) I consent to the disposal, by the authorities of the hospital where such an operation shall be conducted, of any bodily tissues or parts that may be removed.

4) I understand there is a tremendous amount of time and expense of the medical team associated with preparing for a surgical procedure and any request to cancel or reschedule surgery must be made within 48 hours of the date listed above. Failure to provide inadequate notice, or failure to show for the surgical procedure shall result in a $3,000.00 charge.

5) For advancing medical education, and for the purposes of my medical records at the discretion of the physician, I also consent to admittance of observers to the operation room and to the taking and publishing any photographs and/or videos during this operation.

I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE CONSENT TO OPERATE, THE EXPLANATIONS REFERRED TO WERE MADE, AND THAT ALL BLANKS OR STATEMENTS REQUIRING INSERTION OF COMPLETION WERE FILLED IN BEFORE I SIGNED. FURTHERMORE, I HEREBY ACKNOWLEDGE THAT I HAVE HAD TO OPPORTUNITY TO ASK THE ABOVE-NAMED SURGEON ANY QUESTIONS I MIGHT HAVE CONCERNED THIS SURGERY.

When a patient is a minor or incompetent to give consent:

The foregoing consent was read, discussed, and signed in my presence and, in my opinion; the person signing did so freely with knowledge and understanding.