Surgical Consent Form - Consultant Patient Name(Required)Patient Email(Required) Date of Birth(Required) DD slash MM slash YYYY Consultant(Required)Prof Lennard FunkProf Adam WattsMr Michael WaltonMr David MurrayMr Neil JainStatement of health professionalTo be completed by health professional with appropriate knowledge of proposed procedureName of proposed procedure or course of treatment(Required)Intended benefits(Required)General: Improve symptoms of pain and functionSerious or frequently occurring risks(Required)Most of these complications are rare, but could have significant implications: Infection, bleeding, blood collection, blood vessel injury or wound problems that could require further surgery or lead to permanent disability; Nerve or tendon injury that could leave you with numbness or weakness with loss of use of your arm; Excess scarring that may require treatment; Ongoing or recurrent symptoms; Non-healing or failure of repair (if a repair is done) that can lead to recurrent symptoms; Regional pain syndrome that could give you long-term pain and/or stiffness; heart attack, stroke or blood clots that could lead to death. Anaesthetic complications, which will be discussed in more detail by your aneasthetist on admission. Covid related complications.Additional Procedure benefits:Additional Procedure Specific Risks:I have also discussed what the procedure is likely to involve, the possibility of any extra procedures which may become necessary during the procedure, the benefits of any available alternative treatments (including no treatment) and any particular concerns of this patient/parent.The following information has been provided: Shoulderdoc Leaflet Shoulder Surgery Booklet MyRecovery SOS Outcomes Scoring System information The procedure will involve: General and/or regional anaesthesia Local anaesthesia Sedation Surgeon Signature(Required)Date(Required) DD slash MM slash YYYY Surgeon Name:(Required)Job title:Statement of patientOnce filled in please submit. It will be sent to the patient to complete. You will be informed upon completion. Δ
