Note: This form is intended as a sample form of the information that you as the surgeon should personally discuss with the patient. Please review and modify to fit your actual practice. Give the patient a copy and send this form to the hospital or surgery center as verification that you have obtained informed consent.
- Dr. _________________ provided me with the following information
- I have the following condition(s):
- The doctor is recommending the following treatment:
- The recommended treatment involves:
- The purpose of the recommended treatment:
- I need to get the recommended treatment within the following time period:
- The consequences of not proceeding with the recommended treatment or the above described alternative(s):
- I understand that if I do not consent to the recommended treatment, I may endanger my vision, life, or health; I nonetheless refuse to consent to it.
- My reason for refusing this treatment is: