Cedar Vale Surgical Center
Outpatient Care

Informed Consent for Treatment

Please read this consent carefully before your procedure. Your provider will answer any questions before you sign.

1 The procedure

I authorize Cedar Vale Surgical Center and the provider named below to perform the procedure described here, together with any treatment that may be reasonably necessary during it.

Right knee arthroscopy
June 24, 2026
Dr. Anita Rao, MD
2 Risks & acknowledgment

My provider has explained the nature of this procedure, its expected benefits, and the reasonable alternatives, including the option of no treatment. I understand that no procedure is without risk.

  • I understand the common risks may include bleeding, infection, pain, and an adverse reaction to anesthesia or medication.
  • I understand that the practice of medicine is not an exact science and that no guarantee has been made about the result.
  • I have had the opportunity to ask questions, and they have been answered to my satisfaction.
3 Patient details
Jordan T. Mills
03 / 14 / 1986
CV-104882
(555) 412-0098
4 Signature

I have read and understand this consent. I voluntarily consent to the procedure described above.

Jordan T. Mills
Patient signature
June 24, 2026
Date
Dr. Anita Rao
Provider signature (witnessing consent)
June 24, 2026
Date

Cedar Vale Surgical Center · Confidential patient record