Disclosure and Consent for Medical and Surgical Procedures
Good Shepherd Medical Center / Marshall---Marshall, Texas
TO THE PATIENT : You have the right, as a patient to be informed about your condition and the recommended surgical, medical, or diagnostic procedure to be used to that you may make the decision whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give or withhold your consent to the procedure.
I/We voluntarily request Dr. D. Duncan / Dr. D. Waldman as my physician[s] , and such associates, technical assistants and other health care providers as they may deem necessary to treat my condition which has been explained to me as:
I/We understand that the following surgical, medical, and/or diagnostic procedures are planned for me and I/we voluntarily consent and authorize these procedures :
in lay terms: anesthesia, x rays, cast, repair or remove damaged tissue
I/We understand that my physician may discover other or different conditions which require additional or different procedures than those planned. I/We authorize my physician, and such associates, technical assistants and other health care providers to perform such other procedures which are advisable in their professional judgment.
Þ I/We DO DO NOT consent to the use of blood and blood products as deemed necessary.
Þ I/We DO DO NOT consent to the taking of photographs and videos.
Þ I/We DO DO NOT consent to observation of the operation by authorized personnel.
I/We have been given an opportunity to ask questions about my condition, alternative forms or anesthesia and treatment, risks of non-treatment, the procedures used, and the risks and hazards involved and I/We believe that I/We have sufficient information to give this informed consent.
I/We certify that this form has been fully explained to me, that I/We have read it or had it read to me, that the blank spaces have been filled in, and that I/We understand its contents. I authorize the hospital pathologist to use discretion in the disposal of any severed tissue or member except : none.
I/We understand that no warranty or guarantee has been made to me as to result or cure.
Just as there may be risks and hazards in continuing my present condition without treatment, there are also risks and hazards related to the performance of the surgical, medical, and/or diagnostic procedures planned for me. I/we realize that common to surgical, medical, and /or diagnostic procedures is the potential for infection, blood clots in veins and lungs, hemorrhage, allergic reactions, and even death. I/we realize that the following risks and hazards may occur in connection with this particular procedure:
Common : disfiguring scars, need for removal of metallic or other implant; pain and/or discomfort
Uncommon: loss or loss of function of an arm or leg; amputation; other therapy may be found necessary; blood transfusion risks including fever, transfusion reaction, kidney failure, anemia, heart failure, hepatitis, AIDS, other infections; weakness; deformity or shortening of limb; paralysis or foot drop, numbness, limitation of joint motion or stiffness; failure to achieve goals of procedure; infection; recurrence or persistence of original problem
Very uncommon: death; paralysis from neck down or waist down; loss of or loss of function of the operated organs; risk to all major systems of involved limb; brain damage; fat escaping from bone to damage vital organ; failure to heal; blood vessel and/or nerve injury; arthritis or joint degeneration; impaired muscle function
Patient is a minor or unable to sign because: ___________________________________
Signature of Patient or Legally Responsible Person Relationship
811 S. Washington, Marshall, TX 75670
Signature of Witness Address Date and Time
I have counseled this patient as to the nature of the proposed procedure(s), attended risks, benefits, alternatives involved, and expected results, as described above.
Signature of Counseling Physician Revised 2/08 (VALID FOR 7 DAYS AFTER SIGNING)