Surgical consent form

June 20, 2011

A surgical consent form is considered as the medical commitment between the patient and the concerned surgeon, hospital and clinic to initiate the surgical treatment.
Sample surgical consent form:

* Name of the hospital: _______________________
* Hospital Address: _________________________________
* Name of the surgeon: _______________________
* Name of the patient: ________________________
* Type of the surgery: ________________________
* Surgical consent terms:

Have you understood the cause of surgery: _________________?

Have you met your surgeon: ________________________?

Are you ready for the surgery: _______________________?

Are you fully aware about the consequences if the surgery fails: _______________?

Is your family, relatives and guardian aware about your surgery and post surgery requirements: ____________?

Are you taking all the medicines suggested to you before the surgery: ______________?

Have you paid the 50% of the amount for your surgery: _____________________?

Are you taking the full responsibility of your surgery results: ____________?

* Signature of the patient: ____________________
* Signature of the guardian, if minor: ___________
* Signature of the surgeon: __________________
* Date: ___/____/____

 

Download Surgical consent form in Word Format

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