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 _______________ ____________, 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 ____________________, and associates and assistants as designated by ____________________.

I further consent to the examination for anatomical purposes and disposal by 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:
_____________________________________________________________

Dated: ___________________
Time of signature: ___________
______________________________________ ___________________
Signer
_______________________
Witness: ____________________________________

Authorization for Medical Treatment, Anesthesia and Performance of Operation
Review List

This review list is provided to inform you about this document in question and assist you in its preparation. This authorization is important to have signed and filed, especially if you are subject to needing medical treatment. It is a sound well care idea to have it done in any event.

1. Make multiple copies. Give one to your doctor and others to specialists, if there are any involved, so they are handy when needed. Be sure your spouse has one.

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