Bellevue Surgery Center

CONSENT TO OPERATION AND ADMINISTRATION OF ANESTHETICS

Patient: ______Date of Birth: ______

  1. I hereby authorize Dr. ______and/or associates or assistants selected by said physician to treat the following condition(s) which has (have) been explained to me:

______
______
______

  1. The procedures planned for treatment of my condition(s) have
    been explained to me by my physician. I understand them to be:
    ______
    ______
    ______

At BELLEVUE SURGERY CENTER

  1. I have been informed of and understand the expected result of the treatment listed above. I recognize that during the operation, the procedure, post operative care, medical treatment, and anesthesia or follow up treatment, unexpected conditions may necessitate additional or different procedures than those above. I therefore authorize my above named physician, and his or her assistant or designees, to perform other necessary treatment in my best interest. The authority granted under this paragraph shall extend to all conditions that may require treatment and are not know to my physician at the time the medical or surgical procedure is commenced.
  1. I have been informed that there are significant risks such as severe loss of blood, infection and cardiac arrest that can lead to death or permanent or partial disability, which may be attendant to the performance of any procedure. I acknowledge that no warranty or guarantee has been made to me as to result or cure.

Cross out any sections below that do not apply. Both physician and patient should initial the crossed out section.

  1. General anesthesia, regional anesthesia or sedation may be given to me by my attending physician, an anesthesiologist or other qualified person as needed. It has been explained to me that all forms of anesthesia involve some risks, and no guarantees or promises can be made concerning the results of my procedure or treatment. Although rare, severe unexpected complications can occur with each type of anesthesia, including the possibility of infection, bleeding, drug reactions, blood clots, loss of sensation, loss of vision, loss of limb function, paralysis, stroke, brain damage, heart attack, or death.
  1. Any tissue removed may be disposed of by the facility or physician by appropriate procedure.