Informed Consent for Outpatient Surgery
Patient Information
Patient Name
Date of Birth
Medical Record Number
Procedure Information
Name of Procedure
Surgeon's Name
Purpose of Surgery
Risks and Possible Complications
Alternatives to Surgery
Anesthesia
Patient Acknowledgement
I acknowledge that I have read or had the above information explained to me, have had the opportunity to ask questions, and understand the nature and purpose of the procedure, its risks, alternatives, and possible complications.
Patient Signature
Date
Witness Signature
Date