Informed Consent for Neurosurgery Procedure
Patient Name
Date of Birth
Medical Record Number
Procedure Information
Procedure Name
Indication for Procedure
Description of Proposed Procedure
Benefits and Goals
Risks and Complications
List of Possible Risks/Complications
Alternatives
Alternative Treatments (including non-treatment)
Questions
Questions/Concerns Discussed
Consent
By signing below, I acknowledge that I have discussed the procedure, its risks, benefits, and alternatives with my doctor and all of my questions have been addressed to my satisfaction. I voluntarily give my consent for the neurosurgical procedure listed above.
Patient/Legal Representative Signature
Date
Physician Signature
Date