Informed Consent for Outpatient Laparoscopic Surgery

Patient Information

Patient Name: Date of Birth: Medical Record Number:

Surgery Information

Name of Procedure: Date of Surgery: Surgeon:

Description of Procedure

Risks, Complications, and Alternatives Discussed

Consent

I hereby confirm that I have been informed about the nature of the laparoscopic surgery, its purpose, potential risks and complications, benefits, and available alternatives.
All my questions have been answered to my satisfaction.

Patient Signature: Date:

Witness Signature: Date:

Physician Signature: Date: