CONSENT TO SURGICAL OR DIAGNOSTIC PROCEDURES AND WAIVER OF
RIGHT TO RECEIVE INFORMATION IN CONNECTION THEREWITH
DO NOT SIGN THIS FORM WITHOUT READING AND UNDERSTANDING ITS
CONTENTS.
Name of Patient___________________________
Date___________
(A)
(1) I acknowledge and understand that the
following' procedure) which has (have) been described to me is (are) to be
performed on the patient:
________________________________________________
________________________________________________
________________________________________________
(2) I acknowlege and understand
that during the course of the procedure(s) described in subparagraph (A) (1)
above, conditions may develop which may reasonably necessitate an extension of
the original procedure(s) or the performance of procedure(s) which are
unforeseen or not known to be needed at the time this consent is obtained. I
therefore consent to and authorize the persons described in the last paragraph
of this consent to make the decisions concerning the performance of and to
perform such procedure(s) as they may deem reasonably necessary or desirable in
the exercise of their professional judgment, including those procedures that
may be unforeseen or not known to be needed at the time this consent is
obtained. This consent shall also extend to the treatment of all conditions
which may arise during the course of such procedures including those conditions
which may arise during the course of such procedures including those conditions
which may be unknown or unforeseen at the time this consent is
obtained.
(B) I
acknowledge and understand and duly evidence in writing by executing this form
that under Georgia law I am entitled to receive the following information
relative to the procedure(s) described in paragraph (A):
(1) A diagnosis of the condition requiring
the procedure(s);
(2) The nature
and purpose of the procedure(s);
(3) The material risks of the
procedure(s);
(4) The likelihood of
success of the procedure(s);
(5)
The practical alternatives to such procedure(s);
(6) The prognosis if the procedure(s) is
(are) rejected.
(C) I
acknowledge that there are practical alternatives to the procedure (s)
described in paragraph (A) which alternatives reasonably prudent physicians
generally recognize and accept.
(D)
I acknowledge and understand that this request for and consent to surgical or
diagnostic services shall be valid for the responsible
physician, all medical
personnel under the direct supervision and control of the responsible
physician, and for all other medical personnel otherwise involved in the course
of treatment.
I HAVE BEEN GIVEN AMPLE OPPORTUNITY TO ASK QUESTIONS AND ANY
QUESTIONS I HAVE ASKED HAVE BEEN ANSWERED OR EXPLAINED IN A SATISFACTORY
MANNER.
BY SIGNING BELOW, I ACKNOWLEDGE I HAVE READ OR HAD IT READ OR
EXPLAINED TO ME AND I UNDERSTAND THIS FORM AND I VOLUNTARILY CONSENT TO ALLOW
DR. __________________OR ANY PHYSICIAN DESIGNATED OR SELECTED BY HIM OR HER AND
ALL MEDICAL PERSONNEL UNDER THE DIRECT SUPERVISION AND CONTROL OF SUCH
PHYSICIAN AND ALL OTHER PERSONNEL WHICH MAY OTHERWISE BE INVOLVED IN PERFORMING
SUCH PROCEDURES TO PERFORM THE PROCEDURES DESCRIBED OR OTHERWISE REFERRED TO
HEREIN AND I FULLY AND COMPLETELY WAIVE THE RIGHT TO BE INFORMED OF THE
INFORMATION SPECIFIED IN PARAGRAPH (B) AND REQUEST THAT SUCH INFORMATION NOT BE
DISCLOSED.
_____________________________________________
Witness
_____________________________________________
Signature of patient or other person authorized to sign
