CONSENT TO SURGICAL OR DIAGNOSTIC PROCEDURES AND WAIVER OF RIGHT TO RECEIVE INFORMATION IN CONNECTION THEREWITH
DO NOT SIGN THIS FORM WITHOUT READING AND UNDERSTANDING ITS CONTENTS.
Name of Patient___________________________ Date___________
(A)(1) I acknowledge and understand that the following' procedure) which has (have) been described to me is (are) to be performed on the patient: ________________________________________________
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(2) I acknowlege and understand that during the course of the procedure(s) described in subparagraph (A) (1) above, conditions may develop which may reasonably necessitate an extension of the original procedure(s) or the performance of procedure(s) which are unforeseen or not known to be needed at the time this consent is obtained. I therefore consent to and authorize the persons described in the last paragraph of this consent to make the decisions concerning the performance of and to perform such procedure(s) as they may deem reasonably necessary or desirable in the exercise of their professional judgment, including those procedures that may be unforeseen or not known to be needed at the time this consent is obtained. This consent shall also extend to the treatment of all conditions which may arise during the course of such procedures including those conditions which may arise during the course of such procedures including those conditions which may be unknown or unforeseen at the time this consent is obtained.(B) I acknowledge and understand and duly evidence in writing by executing this form that under Georgia law I am entitled to receive the following information relative to the procedure(s) described in paragraph (A): (1) A diagnosis of the condition requiring the procedure(s);(2) The nature and purpose of the procedure(s);(3) The material risks of the procedure(s);(4) The likelihood of success of the procedure(s);(5) The practical alternatives to such procedure(s);(6) The prognosis if the procedure(s) is (are) rejected.(C) I acknowledge that there are practical alternatives to the procedure (s) described in paragraph (A) which alternatives reasonably prudent physicians generally recognize and accept.(D) I acknowledge and understand that this request for and consent to surgical or diagnostic services shall be valid for the responsible physician, all medical personnel under the direct supervision and control of the responsible physician, and for all other medical personnel otherwise involved in the course of treatment. I HAVE BEEN GIVEN AMPLE OPPORTUNITY TO ASK QUESTIONS AND ANY QUESTIONS I HAVE ASKED HAVE BEEN ANSWERED OR EXPLAINED IN A SATISFACTORY MANNER.
BY SIGNING BELOW, I ACKNOWLEDGE I HAVE READ OR HAD IT READ OR EXPLAINED TO ME AND I UNDERSTAND THIS FORM AND I VOLUNTARILY CONSENT TO ALLOW DR. __________________OR ANY PHYSICIAN DESIGNATED OR SELECTED BY HIM OR HER AND ALL MEDICAL PERSONNEL UNDER THE DIRECT SUPERVISION AND CONTROL OF SUCH PHYSICIAN AND ALL OTHER PERSONNEL WHICH MAY OTHERWISE BE INVOLVED IN PERFORMING SUCH PROCEDURES TO PERFORM THE PROCEDURES DESCRIBED OR OTHERWISE REFERRED TO HEREIN AND I FULLY AND COMPLETELY WAIVE THE RIGHT TO BE INFORMED OF THE INFORMATION SPECIFIED IN PARAGRAPH (B) AND REQUEST THAT SUCH INFORMATION NOT BE DISCLOSED.
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Witness
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Signature of patient or other person authorized to sign
Ga. Comp. R. & Regs. R. dept. 360, ch. 360-14, exh. (360-14) B