Informed Consent for Hand Microsurgery
Patient Name:
Date of Birth:
Proposed Procedure:
Indication for Surgery
Risks and Complications
Infection
Bleeding / Hematoma
Nerve injury / numbness / weakness
Vessel injury
Failure of surgical repair
Scarring
Stiffness / Loss of motion
Chronic pain
Other:
Benefits and Alternatives
Acknowledgements
I have had the opportunity to ask questions and they have been answered.
I understand the risks, benefits, and alternatives.
I consent to the proposed hand microsurgery.
Patient/Guardian Signature
Date
Physician Signature
Date