2 page due 10/5

SURGERY CONSENT FORM

DO NOT SIGN WITHOUT READING! I have read, or have had read to me, and understand the following authorization for: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ I authorize Dr. ________________________________________to perform the above described procedure or treatment. I have discussed my medical condition, the proposed treatment or procedure, alternatives to this treatment and the risks associated with them with my physician. I have been informed that in the performance of any invasive procedure, there is the potential for damage to my organs, nerves, or blood vessels. There is also the possibility of an allergic reaction, blood clots, inadvertent puncture, laceration, infection, consequent hemorrhage, dislodgement or displacement of implanted devices, paralysis, and very rarely death. I fully understand that it may be necessary to proceed with additional procedures to repair an injury or control and treat the complications. I specifically request my physician to proceed with whatever is deemed medically necessary and request that I be given a full explanation after the effects of sedation have subsided. I agree to the administration of blood or blood products if they are required. (Potential risks of blood transfusions include the risk of hepatitis, AIDS, or other infections or reactions. I agree that any tissue or parts surgically removed may be disposed of in accordance with the hospital's accustomed practice, which may or may not include utilizing any tissue not needed for my care for general research. No personal information will be shared. I agree that my physician may permit photographs or video tapes of my procedure or treatment, employing appropriate privacy draping of my person, to record the procedure for the express purpose of medical education or to provide a record to be filed with my medical records. I consent to the observation of my procedure or treatment by individuals for the purposes of medical education and to the presence of a medical representative in the operating room. I understand medical representative to mean non-medical technician of companies that have furnished and may assist with operation of operating room equipment and supplies. I have been informed that other practitioners may be performing important aspects of the procedure, such as opening and closing, dissecting tissue, removing tissue, harvesting grafts, transplanting tissue, administering anesthesia, implanting devices and placing invasive lines.

I have had the opportunity to have my questions answered to my satisfaction. □ “Language Line” SM used for interpretation. I authorize my physicians and Martin Memorial to disclose health information related to this treatment or procedure to any friend or family member who has accompanied me or who is waiting for me, even if I am competent or available, with the exception of the following: ______________________________________________________________________ ________________________________________ ________________________________ Patient/Authorized Surrogate Or Proxy Signature Date/Time ________________________________________ __________________________ Witness Signature Date/Time I certify that I have explained the nature, purpose, benefits, risks, complications, and alternatives of the proposed procedure to the patient or the patient's legal representative. I have answered all questions fully, and I believe that the patient/legal representative fully understands what I have explained. I further certify that I have validated the procedure/site and side, and that the correct procedure site has been marked, if indicated, prior to the procedure being performed. __________________________________________ __________________________ Practitioner Signature Date/Time

MARTIN MEMORIAL HEALTH SYSTEMS STUART, FL

SURGERY CONSENT RM056 Rev 11/00 2/01, 6/03, 10/05, 2/06, 3/07, 5/07, 4/08, 01/09; 7/11; 1/12; 5/12

G/Consent Forms/surgical consent 056 REVISIONS MADE TO THIS CONSENT MUST BE APPROVED BY RISK

MANAGEMENT.

Patient Label