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 benets 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, benets and alternatives, benets 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 specic 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 benets, risks and side effects including but not limited to
I have been advised of the alternatives, benets 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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