Surgical Consent Form

Patient's Name(Required)

Patient Email(Required)

Date of Birth(Required)

Consultant(Required)

Statement of health professional

To be completed by health professional with appropriate knowledge of proposed procedure

Name of proposed procedure or course of treatment(Required)

Intended benefits(Required)

Serious or frequently occurring risks(Required)

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

The procedure will involve:

General and/or regional anaesthesia

Local anaesthesia

Sedation

Surgeon Signature(Required)

Date(Required)

Surgeon's Name:(Required)

Job title:

Statement of patient

Please read this form carefully. if you have any further questions, do ask - we are here to help you. You have the right to change your mind at any time, including after you have signed this form.

Patient/Parent Signature:(Required)

Date(Required)

Name:(Required)

Relationship:

(If signing for a person under 16 years please indicate relationship to the patient)

Statement of health professional

Statement of patient

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