Informed Consent for Orthopedic Surgery

Patient Information

Patient Name Date of Birth Medical Record Number

Procedure Information

Name of Surgery/Procedure Surgeon's Name Description of Procedure

Risks and Complications

Risks and Possible Complications

Benefits

Expected Benefits

Alternatives

Alternatives to This Procedure

Consent Confirmation

I confirm that I have read and understood the above information and had the opportunity to ask questions. I consent to the orthopedic surgical procedure described above.

Signatures

Patient Signature Date Witness Signature Date