Author: nancy
Last saved by: Andrew J. Schneider
Company: ben

CONSENT FOR SURGERY OR OTHER PROCEDURES

PATIENT:		AGE:  		DATE:  		TIME:  
I hereby authorize Dr. Thomas Truong, DPM and whomever he may designate as assistants to perform upon the following surgical treatment or procedure:  If during the course of the surgical treatment or operation, other different operating procedures appear advisable, I further grant permission to perform such procedures as if they had been specifically authorized.

I consent to the administration of anesthesia under the direction of the above named physician as he deems advisable.

The nature and purpose of the surgical treatment or operation, possible alternative methods of treatment, the risks involved, and the possibility of complications have been fully explained to me by Thomas Truong, DPM.
I acknowledge that no guarantee or assurance has been made as to the results that may be obtained.

Any tissue removed may be disposed of by the Physician in accordance with the usual accustomed procedure.

I certify that I have read and fully understand the above consent to surgery, which explanations were made by Thomas Truong, DPM, and that all blanks or statements requiring insertion or completion were filled in and inapplicable paragraphs, if any, were stricken in my presence before I signed.

SIGNATURE OF PATIENT:_______________________________________________________________

SIGNATURE OF PARENT OR
GUARDIAN IF MINOR:________________________________________________________________

RELATIONSHIP TO PATIENT:______________________________________________________________

The foregoing consent was read, discussed and signed in my presence and in my opinion, the person(s) so signing did so freely with full knowledge and understanding.

SIGNATURE OF WITNESS:___________________________________DATE______________________