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CONSENT FOR SURGERY / OPERATION / PROCEDURE(S) …

CONSENT FOR SURGERY / OPERATION / PROCEDURE(S). 1. I authorize the performance of the following OPERATION / surgical procedure(s). to be performed upon_____. by or under the direction of 2. I UNDERSTAND THAT THE PHYSICIANS, ANESTHESIOLOGISTS, DENTISTS AND / OR PODIATRISTS WHO PARTICIPATE IN THE. OPERATIONS OR PROCEDURE ARE INDEPENDENT CONTRACTORS AND ARE NOT EMPLOYEES OR AGENTS OF THE SURGERY . CENTER, AS FULLY SET FORTH IN THE ACKNOWLEDGEMENT OF UNDERSTANDING OF SERVICES PROVIDED BY INDEPENDENT. CONTRACTORS PROVIDED TO AND EXECUTED BY ME OR MY REPRESENTATIVE. _____. Patient's Initials 3. My physician(s) has fully explained to me the condition requiring treatment and the nature, purpose, risk and benefits of the OPERATION (s) /. procedure(s), possible alternative methods of treatment, including non-treatment, and the possibility of complications.

the matters above. I represent that (a) I have the full right to consent to the matters above; (b) I agree to release, indemnify, and hold harmless the surgery center, its employees, agents, medical staff, partners, and affiliates from any liability or cost arising out of my lack of adequate authority to provide the consent set forth herein. 19.

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Transcription of CONSENT FOR SURGERY / OPERATION / PROCEDURE(S) …

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