Informed Consent for Cardiac Surgery
Patient Information
Patient Name
Date of Birth
Medical Record Number
Procedure Information
Type of Cardiac Surgery
Description of Surgery
Reason for Surgery
Risks and Benefits
Potential Risks
Expected Benefits
Alternatives
Alternative Procedures/Treatments
Anesthesia
Type of Anesthesia
Risks of Anesthesia
Patient Acknowledgement
I have received and understand the explanation of the procedure, its risks, benefits, and alternatives.
All my questions have been answered to my satisfaction.
I voluntarily agree to proceed with the surgery.
Signatures
Patient Signature
Date:
Physician/Surgeon Signature
Date:
Witness Signature
Date: