Informed Consent for Robotic-Assisted Surgery
Patient Information
Patient Name
Date of Birth
Medical Record Number
Procedure Information
Proposed Procedure
Physician/Surgeon
Proposed Date
PURPOSE
DESCRIPTION OF THE PROCEDURE
BENEFITS
POTENTIAL RISKS AND COMPLICATIONS
ALTERNATIVE TREATMENTS
ACKNOWLEDGEMENT AND CONSENT
I confirm that I have read and understood the above information.
I have had the opportunity to ask questions and they have been answered to my satisfaction.
I voluntarily consent to undergo the robotic-assisted surgical procedure as described.
Signature
Patient/Representative Signature
Date
Witness Signature
Date
Physician/Surgeon Signature
Date