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Consent To Surgery And Release
Consent and release executed by (name), of (address), as releasor, to (hospital) located at (address), its directors, medical and surgical staff, agents, employees and any other person connected with the surgery hereafter to be performed on releasor with (his or her) consent.
Releasor understands and agrees that:
1. After extensive medical testing and diagnoses, it is the opinion of the medical staff of (hospital) that releasor is suffering from (disease or condition that has arisen as a result of [Describe]).
2. Releasor faces the possibility of death or serious disability unless surgery described generally as follows is performed without delay:
(describe the surgery). Releasor has been advised by (Name).
(physician), a member of the professional staff of (Name).
(hospital), as to the dangers associated with, and possible complications from, such surgery.
3. Certain resident physicians and surgeons at (hospital) are qualified and willing to perform the surgery.
4. Before such surgery will be performed, releasor must consent thereto and must release the physicians and surgeons who propose to perform the surgery, as well as (hospital) and its medical staff, agents and employees, from all liability that may result from the surgery.
In consideration of the surgery to be performed and any further surgery that may, in the opinion of the medical staff of (hospital) be necessary, releasor, fully realizing that such surgery may be unsuccessful, that it may have certain complications, including, but not limited, to:
(enumerate possible consequences), and that possible results of such complications are (enumerate), requests that such surgery be performed, and expressly consents thereto. Releasor hereby releases and forever discharges (hospital), its directors, medical and surgical staff, agents, employees and any other persons connected with such surgery, from all claims, damages and causes of action that may arise from the surgery herein described, and from other medical care arising therefrom, including post-surgical treatment while releasor remains a patient at (hospital).
Releasor agrees that no representations have been made regarding the success of this surgery to releasor, except as set forth in this consent and release.
This release shall be binding on (Name), (if appropriate: and (Name), the spouse of releasor,)and on the heirs, legal representatives and assigns of releasor.
Releasor has read all the terms of this instrument and understands that (he or she) is signing a complete release and bar to any claim resulting from the surgery herein described.
In witness whereof, releasor has executed this release at (designate place of execution) on (date).
Executed in the presence of:
*** 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]