Education Autonomy & Ethical Principles of Care Assignment

DISCLOSURE AND CONSENT FOR CHOLECYSTECTOMY

TO THE PATIENT: You have the right to be informed about 1) your condition, 2) the recommended medical care or surgical procedure, and 3) the risks related to this care/procedure. This disclosure is designed to provide you this information, so that you can decide whether to consent to receive this care/procedure. Please ask your physician/health care provider any remaining questions you have before signing this form.

Description of Medical Care and Surgical Procedure(s) and other health care

providers, to treat my condition which is: I voluntarily request my physician/health care provider

(Diagnosis)

I understand that the following care/procedure(s) are planned for me (patient/other legally responsible person initial):

____ Cholecystectomy with or without Common Bile Duct Exploration

____ Robotic Assisted Cholecystectomy

____ Laparoscopic Cholecystectomy

Potential for Additional Necessary Care/Procedure(s)

I understand that during my care/procedure(s) my physician/health care provider may discover other conditions which require additional or different care/procedure(s) than originally planned.

I authorize my physicians/health care providers to use their professional judgment to perform the additional or different care/procedure(s) they believe are needed.

Use of Blood - Please initial "Yes" or "No":

_____ Yes ____ No I consent to the use of blood and blood products as necessary for my health during the care/procedure(s). The risks that may occur with the use of blood and blood products are:

1. Serious infection including but not limited to Hepatitis and HIV which can lead to organ damage and permanent impairment.

2. Transfusion related injury resulting in impairment of lungs, heart, liver, kidneys, and immune system. 3. Severe allergic reaction, potentially fatal.

Photographing or Videotaping - Please initial "Yes" or "No":

____ Yes ____ No I consent to the photographing or videotaping of the operations or procedures to be performed, including appropriate portions of my body, for medical, scientific or educational purposes, providing my identity is not

revealed by descriptive texts accompanying the pictures.

Manufacturer's Technical Representatives - Please initial "Yes" or "No":

____ Yes ____ No I consent to have one or more manufacturer's technical representatives, as requested by my physician in the room during the procedure. I understand that one or more representatives from the equipment and/or Supply Company for the products the physician will use during my procedure, may be present for the procedure but will not perform any portion of the procedure. I further understand that all manufacturer's technical representatives present have confidentiality agreements and that none of my personal health information will be disclosed to anyone other than my caregivers with the hospital.

____ Yes ____ No I consent to the disposal by hospital authorities of any tissue or parts which may be removed.

PATIENT IDENTIFICATION

DISCLOSURE AND CONSENT FOR CHOLECYSTECTOMY

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DISCLOSURE AND CONSENT FOR CHOLECYSTECTOMY

Risks Related to this Care/Procedure(s)

Just as there may be risks and hazards to my health without treatment, there are also risks and hazards related to the care/procedure(s) planned for me.

I understand that all care/procedure(s) involve some risks, ranging from minor to severe. These risks include infection, blood clots in veins, lungs or other organs, hemorrhage (severe bleeding), allergic reactions, poor wound healing, and death.

The chances of these occurring may be different for each patient based on the care/procedure(s) and the patient's current health.

Risks of this care/procedure(s) include, but are not limited to [include additional risks if any]: • For Laparoscopically assisted procedure,

- Conversion of the procedure to an open procedure. - Puncture of the bowel or blood vessel - Abdominal infection and operation to correct injury - Abdominal incision and operation to correct injury

• Pancreatitis • Injury to tube between the liver and the bowel • Retained stones in the tube between the liver and the bowel • Narrowing or obstruction of the tube between the liver and the bowel • Injury to the bowel and/or intestinal obstruction • If prolonged fluoroscopy is used:

- Skin injury (such as hair loss, burns or ulcers) • •

Granting of Consent for this Care/Procedure(s) In signing below, I consent to the care/procedure(s) described above. I acknowledge the following:

• I understand this care/procedure(s) does not guarantee a result or a cure to my condition. • I have been given an opportunity to ask questions I may have about:

1. Alternative forms of treatment, 2. Risks of non-treatment, 3. Steps that will occur during my care/procedure(s), and 4. Risks and hazards involved in the care/procedure(s).

• I believe I have enough information to give this informed consent. • I certify this form has been fully explained to me and the blank spaces have been filled in. • I have read this form or had it read to me. • I understand the information on this form.

If any of those statements are not true for you, please talk to your physician/health care provider before continuing.

Patient/Other Legally Authorized Representative (signature required):

Print Name Signature

PATIENT IDENTIFICATION

DISCLOSURE AND CONSENT FOR CHOLECYSTECTOMY

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DISCLOSURE AND CONSENT FOR CHOLECYSTECTOMY

If Legally Authorized Representative, list relationship to Patient:

Date:  Time:  AM/PM 

Witness:

Print Name  Signature 

Address (Street or P.O. Box) 

City, State, Zip Code 

Second Witness if Telephone Consent:

Print Name Signature

Language Services Used Yes No Language Provider Confirmation Number:

Physician Attestation I have explained the Risks, Hazards and Benefits involved in the medical care, technical and/or surgical procedure(s) outlined on  this consent form to the patient or the person authorized to give informed consent prior to their consent. If written materials  explaining the Risks/Hazards/Benefits are required to be provided to the patient by the provider performing the medical care  and/or surgical procedure, those have been provided. 

Physician Signature:  Date:  Time:  AM/PM 

Consent and Disclosure Form Adopted from the Texas Administrative Code Figure: 25 TAC §601.4(a)(1). 

PATIENT IDENTIFICATION 

DISCLOSURE AND CONSENT FOR CHOLECYSTECTOMY

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7777 Forest Lane • Dallas, Texas 75230 • (972) 566-7000

1. my physician health care provider:
2. Diagnosis:
3. Cholecystectomy With or Without Bile Duct Exploration: Off
4. Robot Assisted Cholecystectomy: Off
5. Robot Assisted Cholecystectomy patientother legally responsible person initial:
6. Laparoscopic Cholecystectomy: Off
7. Laparoscopic Cholecystectomy patientother legally responsible person initial:
8. I consent to the use of blood and blood products as necessary for my health during the care procedures Yes Initial:
9. I consent to the use of blood and blood products as necessary for my health during the care procedures No Initial:
10. I consent to the photographing or videotaping of the operations or procedures to be performed Yes Initial:
11. I consent to the photographing or videotaping of the operations or procedures to be performed No Initial:
12. I consent to have one or more manufacturers technical representatives as requested by my physician in the room during the procedure Yes Initial:
13. I consent to have one or more manufacturers technical representatives as requested by my physician in the room during the procedure No Initial:
14. I consent to the disposal by hospital authorities of any tissue or parts which may be removed Yes Initial:
15. I consent to the disposal by hospital authorities of any tissue or parts which may be removed No Initial:
16. Risks of this care procedures include but are not limited to include additional risks if any Line 1:
17. Risks of this care procedures include but are not limited to include additional risks if any Line 2:
18. Print Name:
19. Signature:
20. If Legally Authorized Representative list relationship to Patient:
21. Date:
22. Time:
23. AM PM: []
24. Print Name Witness:
25. Signature Witness:
26. Address Street or PO Box:
27. City State Zip Code:
28. Print Name Second Witness:
29. Signature Second Witness:
30. Language Services Used:
31. Language Provider Confirmation Number:
32. Physician Signature:
33. Date Physician Attestation:
34. Time Physician Attestation:
35. AM PM Physician Attestation: []
36. Cholecystectomy with or without Common Bile Duct Exploration patientother legally responsible person initial: