CONSENT TO MEDICAL TREATMENT AND OPERATION
I, ______________________________ (Name), being a patient at
having been fully informed by Dr. ________________________________, a physician
and surgeon, of the risks and possible consequences involved in certain medical
and surgical treatment consisting of _________________________________, hereby
consent to and authorize the administration and performance of such treatment
and operation at _____________________________ (Hospital),
including the arrangements for anesthesia, except _____________________ (Spinal Anesthesia or as the case may be),
and any preliminary, further, or additional treatments and operations, tests,
transfusions, injections that may be, in the judgment of Dr. _________________,
or any other physician and surgeon associated with or by Dr.
____________________, considered or deemed advisable or necessary at the time
the contemplated treatment or operation is being performed.
My intention is to grant full authority to such
physicians and surgeons and ________________________________ (Hospital), and their respective employees
and assistants, to administer and perform all and any drugs, treatments, tests,
or diagnostic procedures to or on me that may be deemed advisable or necessary
by the designated physician or surgeon, or any physicians or surgeons
associated with Dr. ____________,
or anyone acting under their instructions.
Signature of Patient or Person Authorized Date
to Consent For Patient
Relationship to Patient