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FORMS Informed Consent (For Procedures)

This document is a consent form for medical or surgical procedures at the Tabina Rural Health Unit. It outlines that the patient has been informed of their condition, the recommended procedure, its purpose and risks, alternative options, and the risks of not having the procedure. The patient acknowledges that no guarantees have been made, that they understand what was discussed and the contents of the form, and that they voluntarily consent to the recommended procedure.

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922 views1 page

FORMS Informed Consent (For Procedures)

This document is a consent form for medical or surgical procedures at the Tabina Rural Health Unit. It outlines that the patient has been informed of their condition, the recommended procedure, its purpose and risks, alternative options, and the risks of not having the procedure. The patient acknowledges that no guarantees have been made, that they understand what was discussed and the contents of the form, and that they voluntarily consent to the recommended procedure.

Uploaded by

Jessa Mae
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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TABINA RURAL HEALTH UNIT

CONSENT FOR MEDICAL/SURGICAL


PROCEDURES/INTERVENTIONS
TO THE PATIENT: You have been given information about your condition and the
recommended surgical, medical, or diagnostic procedure(s). This consent form is designed to
provide a written confirmation of these discussions.
1. Tabina RHU Health Staff has explained to me that I have the following condition(s)
_______________________________________________________________________
(explain in lay terms)
2. The following procedure/intervention/anesthesia (if any) has been recommended:
_______________________________________________________________________
(explain in lay terms)
3. The following have been explained to me about the procedure/intervention/anesthesia (if
any):
a. Its purpose and nature.
b. The potential benefits and risks.
c. The likely result if I do not have the recommended procedure/intervention.
d. The available alternative treatments and their benefits and risks.
4. The most likely and most serious risks of the procedure(s) are:
_________________________________________________________________
6. I am aware that there may be other risks or complications not discussed that may occur. I
also understand that during the course of the proposed procedure, unforeseen conditions may
be revealed requiring the performance of additional procedures, and I authorize such
procedures to be performed.
I acknowledge that no guarantees or promises have been made to me concerning the results of
this procedure or any treatment that may be required as a result of this procedure.
7. I understand what has been discussed with me as well as the contents of this form. I have
been given the opportunity to ask questions and have received satisfactory answers. If you have
not had all of your questions answered to your satisfaction, do not sign this form until you have.
8. I voluntarily consent to the performance of the procedure/intervention/anesthesia (if any)
described above by my clinician or those who work with him/her.

_________________________________________ _________________
Patient Signature Date

_________________________________________ _________________
Witness Signature Date

_________________________________________ _________________
Physician Signature Date

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