Surgical Consent Form

To be completed along with the surgeon.

DD slash MM slash YYYY

Statement of health professional

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

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:
The procedure will involve:
DD slash MM slash YYYY

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.

DD slash MM slash YYYY

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