1. Dr.
Steven Magilen or his designee has discussed my
medical problem with me and has explained the following procedure(s) to be
undertaken in lay terms completely understandable to me. I understand that Dr. Magilen or his designee
may designate assistants to assist him with the procedure listed below:
DEBRIDEMENT OF
ANY AND ALL WOUNDS UNTIL FINALLY HEALED.
2.
I
have been fully informed of and understand the attendant risks and the
possibility of complications, and the medically acceptable alternative to the
above-described procedure(s) including the option to refuse such
procedure(s). These risks or
complications may include scarring, possible damage to blood vessels or
surrounding areas such as organs, nerves, loss of blood or requiring a
transfusion, allergic reactions, heart, liver, kidney or lung complications,
infection and failure to heal.
3.
I
understand that this procedure initially may make the wound
larger due to the removal of necrotic tissue from the margins.
4. I understand the risks and consent to the
administration or transfusion of blood or blood components to me during my
procedure and/or its related treatment, whenever deemed necessary by those
physicians attending to me, with no warranties made in connection with such
blood or blood components.
5. If any unforeseen condition should arise
during the course of the procedure, I do hereby authorize and request Dr.
Magilen and/or his associate(s) to take whatever steps necessary to perform
whatever procedure(s) they deem advisable, which may be in addition to or
different from those now planned and have been discussed with me.
6. I have been made fully aware and acknowledge
that the practice of medicine and surgery are not exact sciences and that no
guarantees or assurances have been made to me regarding expected outcomes.
7. I consent to the proposed procedure by the
above physician(s) and (their) associates.
8. I consent to the taking of photographs or
recordings during the course of this procedure for the purpose of advancing
medical education as may be authorized by my physicians and to the admittance
of qualified observers to the operating/procedure room as determined by the
Facility.
9. There may be interns/students in the
Facility under the direct supervision of the surgeon.
I have read and I understand all of the above, have
had an opportunity to ask questions concerning the procedure and my questions
have been answered to my satisfaction.
_________________________________
__________________________________________________________ __________________________
WITNESS TO SIGNATURE SIGNATURE
OF PATIENT DATE
& TIME
If patient is unable to consent or is a
minor, complete the following:
Patient is unable to consent because __________________________________________________________________
________________________ ____________________________________ ___________________ ______________
WITNESS TO SIGNATURE HEALTHCARE SURROGATE, CONTACT
TELEPHONE # DATE & TIME
LEGAL
GUARDIAN OR NEAREST RELATIVE
PHYSCIAN'S CERTIFICATION:
I, Steven
Magilen, MD or his designee
hereby certifies that the patient, or one authorized to act on his or her
behalf:
(1) Has
been fully informed by me or my physician associates, in lay terms
understandable to the patient, the nature of the procedure, the medically
acceptable alternatives to treatment, including refusal, and the consequences
and risks to the patient inherent or associated with the procedure(s) and
(2) Has
authorized the performance of the procedure(s).
____________________________________________________ ____________________________________
|
Steven Magilen, MD |
Date & Time |
||
|
Malcolm Goldsmith, MD |
Donna Perez, PA-C |
||
|
|
Al Cartas, PA- C |
||
|
Ralph Stegemoller, MD |
|
\PTINFO-O\CONSENT
DEBRIDEMENT
© QSM 2000