TO SURGERY AND RELEASE
and release executed by _____________________________________ (name), of
___________________________________________________________ (address), as
releasor, to __________________________________________ (hospital) located at
_____________________________________________________________ (address), its
directors, medical and surgical staff, agents, employees and any other person
connected with the surgery hereafter to be performed on releasor with
__________ (his or her) consent.
understands and agrees that:
After extensive medical testing and diagnoses, it is the opinion of the medical
staff of _____________________________________ (hospital) that releasor is
suffering from ___________________________________ (disease or condition)
___________ (that has arisen as a result of __________ ).
Releasor faces the possibility of death or serious disability unless surgery
described generally as follows is performed without delay: ______________________________
(describe the surgery). Releasor has been advised by
a member of the professional staff of ______________________________
as to the dangers associated with, and possible complications from, such
Certain resident physicians and surgeons at _________________________________
(hospital) are qualified and willing to perform the surgery.
Before such surgery will be performed, releasor must consent thereto and must
release the physicians and surgeons who propose to perform the surgery, as well
as ___ _____________________ (hospital) and its medical staff, agents and
employees, from all liability that may result from the surgery.
consideration of the surgery to be performed and any further surgery that may,
in the opinion of the medical staff of _____________________________________
(hospital) be necessary, releasor, fully realizing that such surgery may be
unsuccessful, that it may have certain complications, including, but not
(enumerate possible consequences), and that possible results of such
complications are _____________________________
_______________________________________ (enumerate), requests that such surgery
be performed, and expressly consents thereto. Releasor hereby releases and
forever discharges ________________________________ (hospital), its directors,
medical and surgical staff, agents, employees and any other persons connected
with such surgery, from all claims, damages and causes of action that may arise
from the surgery herein described, and from other medical care arising
therefrom, including post-surgical treatment while releasor remains a patient
at ____________________ ________________ (hospital).
agrees that no representations have been made regarding the success of this
surgery to releasor, except as set forth in this consent and release.
release shall be binding on __________________________, (if appropriate: and ___________________, the spouse of
releasor,) and on the heirs, legal representatives and assigns of releasor.
has read all the terms of this instrument and understands that __________ (he
or she) is signing a complete release and bar to any claim resulting from the
surgery herein described.
witness whereof, releasor has executed this release at _________________________
(designate place of execution) on __________ (date).
in the presence of:
(Signatures of witnesses, with names and addresses
indicated for each person)