Free Legal FormsLegal Forms
Need Help Contact Us Find out more about us. Customer/Member Support
  Members Logon
 User Name
Forgot Your Password?
View forms index

Do-it-yourself, and save-but be smart about it!

To make sure your goals are not compromised, and that your needs are properly met, All About Forms highly recommends that you have a licensed attorney review any legal documents you plan to use.


  • To be sure you have the right form for your state or local area.
  • To be sure you have the right form for your unique situation.
  • To be sure you are considering all possible legal ramifications.

Signup now to take advantage of the free consultations with our attorneys and financial experts and have them take a look at what you're planning. Just in case!

Back to Forms for 'Medical Consents & Releases'.




Consent 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.


Releasor understands and agrees that:


1. 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 __________ ).


2. 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 ___________________________

(physician), a member of the professional staff of ______________________________

(hospital), as to the dangers associated with, and possible complications from, such surgery.


3. Certain resident physicians and surgeons at _________________________________ (hospital) are qualified and willing to perform the surgery.


4. 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.


In 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 limited, to: 



_________________________________________ (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).


Releasor agrees that no representations have been made regarding the success of this surgery to releasor, except as set forth in this consent and release.


This release shall be binding on __________________________, (if appropriate:  and ___________________, the spouse of releasor,) and on the heirs, legal representatives and assigns of releasor.


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.


In witness whereof, releasor has executed this release at _________________________

___________________________ (designate place of execution) on __________ (date).



_____________________________________                   _______________________

Signature                                                                               Date


Executed in the presence of:







(Signatures of witnesses, with names and addresses indicated for each person)



Printer Friendly Version Get RTF Version


 ©2000-2012 CLC Inc.

 Home | About Us | Contact Us | FAQs | Link to Us
 Legal Information | Privacy Policy

Try us out for only $4.95!

Register now

FIFA 14 Coins,FIFA Coins,MMORPG Gold,MMOPRG Game,Wedding Dresses,Evening Dresses,Fashion Guides,Fashion Tips,Healthy Diets,Slimming Equipment,Fashion Bags,Fashion Handbags,Fashion Clothes,Fashion Shoes,FIFA 14 Coins,FIFA Coins,Fashion Jewelry,Fashion Jewellery,Fashion News,Fashion Tips,FIFA 14 Coins,FIFA Coins,Fashion Guides,Fashion Trends,Wedding Dresses,Evening Dresses,Wedding Dresses,Evening Dresses