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Authorization For Medical Treatment
ANESTHESIA AND PERFORMANCE OF OPERATION
I, as of hereby authorize and associates and assistants as designated by to perform the following medical procedure:
It has been explained to me that during the course of the operation or procedure, unforeseen conditions may be revealed or encountered in that necessitate surgical or other procedures in addition to or different from those contemplated, I further require and authorize [Name], associates and assistants, to perform additional procedures as they may deem immediately necessary.
I consent to administration of anesthesia and to the use of such anesthetic as may be deemed necessary.
I further consent to the administration of such drugs, infusions, plasma or bloods transfusion deemed necessary in the judgment of [Name], and associates and assistants as designated by .
I further consent to the examination for anatomical purposes and disposal by authorities of the hospital of any bodily tissues and parts that may be removed during the procedure.
I also consent to photographing, videotaping, or closed circuit televising, and the publication regarding the operations(s) or procedure(s) to be performed provided my identity is not revealed and that the use is limited to medical, scientific or educational purposes. I waive all rights that I may have to any claims for payment in connection with the exhibition of the recordings.
The nature and purpose of the procedure, its necessity, and
possible alternative methods of treatment, the risks involved, and the possibility of complication in the treatment of my condition have been fully explained to me, and I understand them. I recognize that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantees or assurances have been made to me concerning the results of this procedure.
This consent is given by due to the inability of to give consent because:
Time of signature: _______ A.M./P.M.
*** If Required By State Law ***
This Section for Notary:
STATE OF -------)
) ss: [date]
COUNTY OF ------)
On [Date] before me, [Name of Notary], notary, personally appeared [Name of Person(s) Involved], personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
Witness my hand and official seal.
[Name of Notary Public]
My commission expires: [date]