SIDE 1 OF 1
OR2C261 (10/16)
I understand that the practice of medicine is not an exact science and I acknowledge that I have received no guarantees
about the benets or results of this treatment. I have read this entire document and understand it. I have been given the
opportunity to ask questions and my questions have been answered to my satisfaction.
An interpreter or special assistance was used
*If other than Patient, provide a reason
(Age 18 or older, other than Practitioner performing procedure)
I verify that I have explained the procedure, relevant risks, benets and alternatives, benets and side effects
related to alternatives, potential problems during recuperative phase, treatment and services, and possible
results of not receiving care.
I consent to the administration of anesthesia and related drugs, as deemed necessary by the staff members from
Stony Brook Anaesthesiology, UFPC.
I understand that unforeseen complications or conditions may arise during this procedure and I consent to any additional
procedures that the physician(s) may deem advisable in their professional judgment.
I understand that portions of the operation/procedure may be photographed or videotaped. I understand that every attempt
will be made to conceal my identity. I understand that some of these photograph/videotapes may be used for teaching and may
not be maintained or be a part of my medical record. I also understand that photographs/videotapes to plan, monitor or
document my treatment may be part of my medical record.
I understand that residents, medical, nursing and allied health students/trainees may be present during the procedure and
they may observe or assist in my care, under the direction of my surgeon and/or other hospital staff members.
I understand that a sales/clinical representative may be present during the procedure, but may not participate in the procedure.
I impose no specic limitations or restrictions on my treatment unless written below:
Signature of Patient or authorized representative
Signature of Practitioner
*COMPLETED CONSENT FORM VALID UP TO FOUR MONTHS*
ID#
Signature of Witness
Relationship (if other than Patient)
Title or Relationship to Patient
(Name of Interpreter) ID# as applicable
Time
Time
Time
Date
Date
Date
X
X
X
This procedure will be performed by
I have been advised that this procedure may have potential benets, risks and side effects including but not limited to
I have been advised of the alternatives, benets and side effects related to the alternatives. I have been advised of the likelihood
of achieving my goals and any potential problems that might occur during recuperation.
I request and consent to a surgical procedure called
and I understand that the purpose of this procedure is
CONSENT TO OPERATION OR PROCEDURE
AND ANESTHESIA
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