Surgical Consent Form
Patient Information
Full Name
Date of Birth
Patient ID/Number
Surgery Information
Procedure/Operation Name
Surgeon
Date of Surgery
Time of Surgery
Location
Consent Statement
I understand the nature of the planned surgery, its purpose, risks, benefits, and alternatives. My questions have been answered to my satisfaction.
I agree and give my consent to proceed.
Additional Notes
Signatures
Patient/Guardian Signature
Date
Witness Signature
Date