Gynecological Surgery Consent Form

Patient Information

Patient Name

Date of Birth

Medical Record Number

Procedure Details

Surgical Procedure Diagnosis/Indication for Surgery Surgeon's Name

Risks and Benefits

Please describe the risks, benefits, and alternatives discussed:

Anesthesia

Type of Anesthesia

Additional Information/Requests

Consent Statement

I acknowledge that I have been informed about my medical condition, the proposed gynecological surgical procedure, the risks, benefits, and alternatives. I have had the opportunity to ask questions and understand the explanations provided.

Patient Signature

Date

Witness Signature

Date