Acute Blood Loss Surgery Consent Form

Patient Name: Date of Birth: Medical Record Number: Date:

Diagnosis

Surgical Procedure

Indication for Surgery

Nature of Surgery

Risks and Complications Associated with the Procedure

— Acute blood loss
— Need for blood transfusion
— Infection
— Bleeding
— Damage to surrounding organs

Benefits and Alternatives

Consent

I have read and understood the information above. I have had the opportunity to ask questions and my questions have been answered. I consent to undergo the proposed surgery and acknowledge the potential risks and alternatives.

Patient/Legal Guardian Signature: Date:

Physician Signature: Date: