Final project

Consents Apr 04,2016

INPATIENT UNIT ========================================================================== *** WORK COPY ONLY *** Printed: Jul 25, 2017 06:37

LOCAL TITLE: CONSENTS DATE OF NOTE: APR 04, 2016@06:00 ENTRY DATE: APR 04, 2016@06:00

AUTHOR: NURSE,FOUR EXP COSIGNER: URGENCY: STATUS: COMPLETED

Patient Consent Form for Operation or Special Procedure

1. Permission: I hereby authorize the doctor (and other such physician (s) at the Hospital as he/she may designate) to perform upon the following operation(s):

Left Radical Mastectomy 2. Unforeseen Conditions: If any unforeseen condition arises in the course of the operation or procedure for which other procedures, in addition to or different from those above contemplated, are necessary or appropriate in the judgment of the said physician or his designee(s), I further request and authorize the carrying out of such operation or procedures. 3. Anesthesia: I consent to the administration of anesthesia under the direction of the Department of Anesthesiology. I understand that certain risks and complications (including damaged teeth) may result from the administration of anesthesia. 4. Specimens: Any organs or tissue surgically removed may be examined and retained by the Hospital for medical, scientific or educational purposes and such tissues or parts may be disposed of in accordance with accustomed practice and applicable State laws and regulations. 5. Photographing, Videotaping, etc: I consent to the photographing, videotaping, televising or other observation of the operation or procedures to be performed including appropriate portions of my body, for medical, scientific or educational purposes, provided my identity is not revealed by the pictures or descriptive texts accompanying them. 6. Explanation of Procedure, Risks, Benefits and Alternatives: The nature and purpose of the operation/procedure, possible alternative methods of treatment, the expected benefits and complications, attendant discomforts and the risks involved have been fully explained to me. I have been given an opportunity to ask questions and all my questions have been answered fully and satisfactorily. 7. I further consent to the administration of blood or blood products as may be considered necessary. I recognize that there are always risks to health associated to the administration of blood or blood products and such risks have been fully explained to me. 8. No Guarantees: I acknowledge that no guarantee or assurance has been made to me as to the results that may be obtained.

I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE CONSENT TO OPERATION THAT THE EXPLANATIONS THEREIN REFERRED TO WERE MADE AND THAT ALL THE BLANK SPACES ABOVE HAVE BEEN COMPLETED PRIOR TO MY SIGNING.

Patient/Relative/Guardian: Electronic Signature

Relationship, if other than patient signed:

/es/ FOUR NURSE FACULTY

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THOMAS, JANE 555-55-5504 Mar 01, 1972 (45)

Jane Thomas

Jane Thomas