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.

Procedure / treatment

Date of procedure

Treating provider

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

Patient full name

Date of birth

Medical record #

Phone

4 Signature

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

Patient signature

Date

Provider signature (witnessing consent)

Date

Cedar Vale Surgical Center · Confidential patient record