Consent for Operations or Special Procedure

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SECTION A
1. After discussing other options, including no treatment, with my doctor, I ask Dr.
and/or his/her partners to perform the following procedure(s):

Name or description of operation(s), procedure(s) and/or treatment(s). Indicate applicable level, side, or site.

I understand that this procedure is for purposes of

2. I give permission to my doctor to do whatever may be necessary if there is a complication or unforeseen condition during my procedure.

3. My doctor has explained to me that some possible complications of the procedure(s) can include:

Bleeding; infection; accidental injury of other body parts; my condition returning or not being improved; or, possibly, death.
My doctor has discussed with me the additional risks listed below and their chances of happening. I do understand that other things can happen as well.

4. I agree to have anesthesia as necessary to perform the procedure(s). I understand that if an anesthesiologist is to be involved he/she will speak to me about the risks of anesthesia in more detail.

5. I understand that I may need to have a blood transfusion during or after the procedure(s). I understand that some risks of blood transfusions include: fever, allergic reaction, or getting an infectious disease. I agree to receive blood or blood products if my doctor decides it is necessary.

6. I give permission to the hospital to keep tissue, blood, body parts, or fluids removed from my body during the procedure and use them to make a diagnosis, after which they may be used for scientific research or teaching by appropriate persons within or outside the hospital. These materials will only be used for scientific research after review by an ethics board. I understand that I will no longer own or have any rights to these things regardless of how they may be used.

7. I understand that Yale-New Haven is a teaching hospital. Doctors who are in training may help my doctor with the procedure. My doctor will supervise these trainees and will be present at all important times during the procedure. I also understand that my doctor’s associate(s), surgical assistants and/or other non-physicians or trainees may assist or perform parts of the procedure under my doctor’s supervision, as permitted by law and hospital policy. If others who are not hospital staff will be present in the operating room, my doctor has spoken with me about this.

8. I understand the purpose and potential benefits of the procedure. My doctor has explained to me what results to expect, and the chances of getting those results. I understand that no promises or guarantees have been made or can be made about the results of the procedure(s).

9. I give permission to the hospital and the above-named doctor to photograph and/or videotape the procedure(s) for medical, scientific, or educational purposes.
Consent signed on

, 20

AM / PM

Signature of Patient or Guardian (Circle one)

Signature of Doctor Performing Procedure

Signature of Person Obtaining Consent

Printed Name

Printed Name

Printed Name

Pg. 1 F1696 (Rev. 10/07)

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Patient is unable to consent for him/herself because (check one):
___ patient is a child (less than 18 years old)___ patient sedated ___patient too severely ill___patient unconscious___ patient not competent

I therefore consent for the patient.

Signature of Person Consenting for Patient

Printed Name

Relationship to Patient

Consent signed on _________, 20 ___ at _______ AM / PM

SECTION B — TELEPHONE CONSENT

I have discussed in a witnessed telephone conversation all of the issues set forth in the CONSENT FOR OPERATION OR SPECIAL PROCEDURE (see

front of page) with the patient’s surrogate/family member. This included a discussion of the risks, their likelihood, and alternative treatment options of
as set forth in Section A, above.
name of operation, procedure or treatment

Consent was obtained by telephone on _____________, 20__ at ________ AM / PM.
Name of person who gave consent:
Relationship to patient:

Signature of Individual Obtaining Consent

Signature of Witness

Printed Name

Witness’s Printed Name

SECTION C — EMERGENCY CONSENT

The patient is in need of a procedure to save the patient’s life, limb or organ and is unable to consent for him/herself and family is currently unavailable despite reasonable efforts.

Signature of Doctor Performing Procedure

This form is available in 12 languages. Please use an interpreter and the appropriate consent form for patients who do not speak English.

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