I hereby authorize my doctor and whomever he may designate as his assistant(s), to perform upon (Patient Name) the following medical or surgical procedure: ___________________.
This procedure(s) has been fully explained to me by Doctor, and I understand (its) (their) nature. I have also had the opportunity to ask questions about this operation/procedure(s), all of which have been answered to my satisfaction. I have been fully informed of the risks and possible consequences involved in the performance of the procedure(s) described above, have been advised that unforeseen results may occur and nevertheless, hereby authorize the above named surgeon and such assistant(s) as he/she may designate to perform the procedure(s) upon me.
I give my permission for the administration of medication and anesthesia for surgery. Local anesthesia is provided for all procedures at this facility. Sedation is available and will be provided by the anesthesiologist under the provision of our conscious sedation protocol. A case begun under the supervision of the anesthesiologist may be passed to the surgeon if the patient is judged stable by the anesthesiologist. An anesthesiologist is available to the facility at all times that patients are here. The advantages and disadvantages of outpatient surgery have been explained to me. I realize that following my operation, admission to a hospital might be advised. I agree to admission to a nearby hospital, if in the opinion of my physician, such admission should be seemed advisable and in my best interest.
I also understand that during the course of the operation, unforeseen conditions may be revealed that necessitate an extension of the original procedure(s) or different procedure(s) than those planned. I authorize the above named surgeon, or his designee(s), to perform such surgical procedures as are necessary and desirable in the exercise of their professional judgment. I recognize that the practice of medicine and surgery is not an exact science and I acknowledge that noguarantees have been made to me concerning the results of the operation or procedure.
Answers I have given to all questions are true to the best of my knowledge and I have not withheld any information. Following surgery, I will have a responsible adult drive me home as per facility policy. I realize that impairment of full mental alertness may persist for several hours following the administration of anesthesia, and I will avoid making decisions or taking part in activities which depend upon full concentration or judgment during that period.
Written instructions and directions have been given to me, and I will read and comply with all of them. If I do not understand my instructions I will call the doctor for clarification.
For the purpose of advancing medical education, I consent to the admission of approved observers to the operating room, as well as the photographing and/or recording of the operation provided my identity is not revealed by the pictures or descriptive text accompanying them.
I consent to the disposal of any tissue which is removed in accordance with accustomed practice and procedure.
I do voluntarily consent to the proposed course of treatment. I hereby release and forever discharge the above named surgeon, The Long Island Ambulatory Surgery Center and such assistant/assistants, or employees of the liability for any injury which may result directly or indirectly from the performance of the operation(s)/ procedure(s).