PLACE LABEL HERE
INFORMED CONSENT
(This form is designed to comply with the Georgia Informed Consent Law O.C.G.A. 31-9-6.1)
PATIENT NAME: ______
The diagnosis or clinical history requiring this procedure is: ______
______
The nature of the procedure is: __________________
______
The purpose of this procedure is: ______
______
THIS PROCEDURE INVOLVES THE MATERIAL RISK OF INFECTION, ALLERGIC REACTION, SEVERE LOSS OF BLOOD, LOSS OR LOSS OF FUNCTION OF ANY LIMB OR ORGAN, PARALYSIS, PARAPLEGIA OR QUADRIPLEGIA, DISFIGURING SCAR, BRAIN DAMAGE, CARDIAC ARREST OR DEATH.
ADDITIONAL RISKS: In addition to the material risks listed above, there may be other potential risks involved in this procedure including, but not limited, to the following: ______
______
The likelihood of success of this procedure is: good fair poor
The practical alternatives to this procedure are: ______
______
If I choose not to have the above procedure, my prognosis (future medical condition) is: ______
______
I understand that during the course of the procedure described above, it may be necessary or appropriate to perform additional procedures which are unforeseen or not known to be needed at the time this consent is given. I consent to and authorize the persons described herein to make the decisions concerning such procedures. I also consent to and authorize the performance of such additional procedures as they deem necessary or appropriate.
I consent to diagnostic studies, tests, x-ray examinations and any other treatment or courses of treatment relating to the diagnosis or procedures described herein. I also consent to and authorize the taking of photographs or videotapes provided that such images will be incorporated into my medical record.
I consent to the use of conscious or deep sedation, as planned by my treating physician. The risks, benefits and alternatives of such sedation have been explained to me. I understand that specific risks of sedation include, but are not limited to, changes in blood pressure, allergic reaction, difficulty breathing, cardiac or respiratory arrest, seizure, coma and death.
I consent that any tissues, specimens, organs or limbs removed from my body in the course of any procedure may be tested or retained for scientific or teaching purposes and then disposed of within the discretion of the physician, facility or other health care provider.
I understand that the physician, medical personnel and other assistants will rely on statements about the patient, the patient’s medical history, and other information in determining whether to perform the procedure or the course of treatment for the patient’s condition and in recommending the procedure which has been explained.
*2-811*FORM 2-811 REV. 10/2018 Page 1 of 2
PLACE LABEL HERE
INFORMED CONSENT
(This form is designed to comply with the Georgia Informed Consent Law O.C.G.A. 31-9-6.1)
I understand that the practice of medicine is not an exact science and that NO GUARANTEES OR ASSURANCES HAVE BEEN MADE TO ME concerning the results of this procedure.
BY SIGNING THIS FORM, I ACKNOWLEDGE THAT THE RISKS, BENEFITS, AND ALTERNATIVES TO THE ABOVE PROCEDURE HAVE BEEN EXPLAINED TO ME, THAT I HAVE READ OR HAD THIS FORM READ AND/OR EXPLAINED TO ME, THAT I FULLY UNDERSTAND ITS CONTENTS, AND THAT I HAVE BEEN GIVEN AMPLE OPPORTUNITY TO ASK QUESTIONS AND THAT ANY QUESTIONS HAVE BEEN ANSWERED SATISFACTORILY. ALL BLANKS OR STATEMENTS REQUIRING COMPLETION WERE FILLED IN AND ALL STATEMENTS I DO NOT APPROVE OF WERE STRICKEN BEFORE I SIGNED THIS FORM. I ALSO HAVE RECEIVED ADDITIONAL INFORMATION, INCLUDING BUT NOT LIMITED TO THE MATERIALS LISTED BELOW RELATING TO THE PROCEDURE DESCRIBED HEREIN.
I hereby voluntarily request and consent for Dr. ______, as my physician, and any other physician(s), and such associates, assistants or other medical personnel involved in performing such procedure(s), to perform the procedure(s) described or referred to herein. I further consent to the presence of device or supply manufacturer’s representatives in the operating room as may be deemed appropriate by my physician.
Additional materials used, if any, during the informed consent process for this procedure include: ______
______
______
DateTimeSignature of Person Giving Consent
Relationship to patient if not the patient: ______
Patient unable to sign because: ______
Responsible Practitioner’s Statement:
I have reviewed the contents of this form, including the risks, benefits and alternatives to the proposed procedure, with the patient or the patient’s decision-maker, and have provided the patient/decision-maker with an opportunity to ask questions.
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DateTimeResponsible PractitionerPID #
Emergency Consent:
I hereby certify that the following elements exist to warrant emergency consent for the surgical or medical treatment or procedures noted above:
- according to competent medical judgment, the proposed surgical or medical treatment or procedures are reasonably necessary,
- a person authorized to consent is not readily available, and
- any delay in treatment could reasonably be expected to jeopardize the life or health of the person affected or could reasonably be expected to result in disfigurement or impaired faculties.
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DateTimeResponsible PractitionerPID #
FORM 2-811 REV. 10/2018 Page 1 of 2