Informed Consent 

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CONSENT FOR SURGERY / PROCEDURE or TREATMENT 

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1. I hereby authorize Thanapoom Boonipat MD and such assistants as may be selected to perform the following 

procedure or treatment: 

I have received the following information sheet:  

1. I recognize that during the course of the operation and medical treatment or anesthesia, unforeseen conditions may necessitate different procedures than those above. I therefore authorize the above physician and assistants or designees to perform such other procedures that are in the exercise of his or her professional judgment necessary and desirable. The authority granted under this paragraph shall include all conditions that require treatment and are not known to my physician at the time the procedure is begun. 

1. I consent to the administration of such anesthetics considered necessary or advisable. I understand that all forms of anesthesia involve risk and the possibility of complications, injury, and sometimes death. 

1. I understand what my surgeon can and cannot do, and understand there are no warranties or guarantees, implied or specific about my outcome. I have had the opportunity to explain my goals and understand which desired outcomes are realistic and which are not. All of my questions have been answered, and I understand the inherent (specific) risks to the procedures I seek, as well as those additional risks and complications, benefits, and alternatives. Understanding all of this, I elect to proceed. 

1. I consent to be photographed or televised before, during, and after the operation(s) or procedure(s) to be performed, including appropriate portions of my body, for medical, scientific or educational purposes, provided my identity is not revealed by the pictures. 

1. For purposes of advancing medical education, I consent to the admittance of observers to the operating room. 

1. I consent to the disposal of any tissue, medical devices or body parts that may be removed. 

1. I am aware that there are potential significant risks to my health with the utilization of blood products, and I consent to their utilization should they be deemed necessary by my surgeon and/or his/her appointees. 

1. I authorize the release of my Social Security number to appropriate agencies for legal reporting and medical-device registration, if applicable. 

1. I understand that the surgeons’ fees are separate from the anesthesia and hospital charges, and the fees are agreeable to me. If a secondary procedure is necessary, further expenditure will be required. 

1. I realize that not having the operation is an option. 

1. IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:  

2. THE ABOVE TREATMENT OR PROCEDURE TO BE UNDERTAKEN 

3. THERE MAY BE ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT 

1. THERE ARE RISKS TO THE PROCEDURE OR TREATMENT PROPOSED 

I CONSENT TO THE TREATMENT OR PROCEDURE AND THE ABOVE LISTED ITEMS (1-12). I AM SATISFIED WITH THE EXPLANATION. 

Signature of Patient or Person Authorized to Sign for Patient: