Patient Information

Full Name

Date of Birth

Medical Record Number

Procedure Details

Procedure Name Indication/Reason for Procedure Planned Date Treating Physician

Risks, Benefits, & Alternatives

Summary of benefits, risks, and alternatives discussed

Patient Consent

I confirm that I have been informed about the nature, purpose, risks, benefits, and possible alternatives to the laparoscopic procedure. My questions have been answered to my satisfaction.

Patient/Representative Signature

Date

Relationship (if not patient)

Physician Statement

I have explained the laparoscopic procedure, alternatives, risks, and benefits to the patient or representative and answered their questions.