Informed Consent for Gender Affirmation Surgery
Patient Information
Full Name:
Date of Birth:
Address:
Phone Number:
Surgery Information
Type of Surgery:
Surgeon's Name:
Facility Name/Location:
Proposed Date of Surgery:
Consent and Understanding
I have discussed my goals and expectations regarding gender affirmation surgery with my healthcare provider.
I understand the risks, benefits, alternatives, and possible complications of the surgery.
I have had the opportunity to ask questions and have them answered to my satisfaction.
I acknowledge that no guarantees can be made regarding the outcome of the surgery.
I understand the potential need for additional treatments or surgeries.
I understand the recovery process and postoperative care instructions.
I understand the possibility of changes in sensation, function, and the permanency of the surgery.
Additional Notes or Concerns:
Patient Signature:
Date:
Provider Signature:
Date: