Authorization for Medical Treatment, Anesthesia and Performance of Operation
I, as __________________ of ___________________ hereby authorize ____________________ and associates and assistants as designated by ____________________ to perform the following medical procedure:
________________________________________________________________It has been explained to me that during the course of the operation or procedure, unforeseen conditions may be revealed or encountered in ___________________ that necessitate surgical or other procedures in addition to or different from those contemplated, I further require and authorize _______________ ____________, associates and assistants, to perform additional procedures as they may deem immediately necessary.
I consent to administration of anesthesia and to the use of such anesthetic as may be deemed necessary.
I further consent to the administration of such drugs, infusions, plasma or bloods transfusion deemed necessary in the judgment of ____________________, and associates and assistants as designated by ____________________.
I further consent to the examination for anatomical purposes and disposal by the hospital of any bodily tissues and parts that may be removed during the procedure.
I also consent to photographing, videotaping, or closed circuit televising, and the publication regarding the operations(s) or procedure(s) to be performed provided my identity is not revealed and that the use is limited to medical, scientific or educational purposes. I waive all rights that I may have to any claims for payment in connection with the exhibition of the recordings.
The nature and purpose of the procedure, its necessity, and possible alternative methods of treatment, the risks involved, and the possibility of complication in the treatment of my condition have been fully explained to me, and I understand them. I recognize that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantees or assurances have been made to me concerning the results of this procedure.
This consent is given by ___________________ due to the inability of ___________________ to give consent because:
_____________________________________________________________Dated: ___________________
Time of signature: ___________
______________________________________ ___________________
Signer
_______________________
Witness: ____________________________________
Authorization for Medical Treatment, Anesthesia and Performance of Operation
Review ListThis review list is provided to inform you about this document in question and assist you in its preparation. This authorization is important to have signed and filed, especially if you are subject to needing medical treatment. It is a sound well care idea to have it done in any event.
1. Make multiple copies. Give one to your doctor and others to specialists, if there are any involved, so they are handy when needed. Be sure your spouse has one.
Frequently Asked Questions
What is an Authorization for Medical Treatment, Anesthesia and Performance of Operation form?
It is a consent document that authorizes a specified medical procedure, the administration of anesthesia, and related treatments. The form also permits the designated physician and their associates or assistants to perform additional procedures if unforeseen conditions arise. It further covers consent to drugs, infusions, plasma or blood transfusions, and examination or disposal of bodily tissues.
Who can sign an authorization for medical treatment?
The form is signed by the individual identified as the authorizing party, typically the patient or their legal representative. The blank line after 'I, as __________________ of ___________________' indicates the signer's capacity and the patient's name. The exact eligibility depends on the applicable legal and hospital requirements.
What does it mean to authorize a medical procedure on this form?
By signing, you authorize the named physician, along with associates and assistants they designate, to perform the medical procedure written on the form. This authorization is limited to the procedure described and any immediately necessary additional procedures. It does not extend to unrelated treatments beyond what the form states.
Can additional procedures be performed if unforeseen conditions are found during surgery?
Yes. The form states that if unforeseen conditions are revealed or encountered during the operation or procedure, the physician and their associates and assistants may perform additional procedures they deem immediately necessary. This authorization applies to surgical or other procedures in addition to or different from those originally contemplated. It is limited to what is immediately necessary.
Does this form give consent for anesthesia?
Yes. The form includes consent to the administration of anesthesia and to the use of such anesthetic as may be deemed necessary. This consent is part of the overall authorization for the medical procedure. It does not specify particular anesthetic agents or methods.
Does the form allow blood transfusions and infusions?
Yes. The form consents to the administration of such drugs, infusions, plasma, or blood transfusions as deemed necessary in the judgment of the named physician and their associates and assistants. This consent is part of the broader authorization for treatment during the procedure. The form does not set limits on the types or amounts of these treatments.
What happens to bodily tissues removed during the procedure?
The form includes consent to the examination for anatomical purposes and disposal by the hospital of any bodily tissues. This means tissues removed during the procedure may be examined and then disposed of by the hospital. The form does not provide further details about the examination or disposal process.
Who can perform the procedure under this authorization?
The procedure may be performed by the physician named in the form, along with associates and assistants as designated by that physician. The form also authorizes these individuals to perform additional procedures if unforeseen conditions arise. The authorization is limited to those designated by the named physician.
Is this form a substitute for a detailed informed consent discussion?
The form is a written authorization for medical treatment, anesthesia, and the performance of an operation. It does not describe the risks, benefits, or alternatives of the procedure. Therefore, it should be used as part of the informed consent process, not as a replacement for a discussion with your physician.
What should I do if I have questions before signing this authorization?
You should ask your physician or the hospital staff to explain any part of the form you do not understand. The form contains blank spaces for the procedure and the names of the parties involved, so you should ensure these are completed accurately. You should not sign until you are satisfied with the explanations provided.
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