Informed Consent for ENT Surgical Procedure
Patient Name:
Date of Birth:
Hospital/Facility:
Procedure Name:
Physician/Surgeon Name:
Description of Procedure
Indication for Surgery
Potential Benefits
Potential Risks and Complications
Alternative Treatments/Procedures
Additional Information/Comments
I acknowledge that I have had the opportunity to ask questions and that all of my questions have been answered to my satisfaction.
Signatures
Patient/Guardian Signature
Date
Physician/Surgeon Signature
Date