Outpatient Surgery Consent Form
Patient Information
Patient Name
Date of Birth
Date of Surgery
Procedure
Physician
Consent & Acknowledgments
I have been informed about the procedure, risks, benefits, and alternatives.
All my questions have been answered to my satisfaction.
I consent to anesthesia as needed for this procedure.
I understand that I am responsible for arranging transportation after the procedure.
Additional Notes
Patient Signature
Date
Witness Signature
Date