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Form #1048

Consent to Surgery and Release

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Consent to Surgery and Release Free Legal Form

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CONSENT TO SURGERY AND RELEASE

 

Consent and release executed by _____________________________________ (name), of ___________________________________________________________ (address), as releasor, to __________________________________________ (hospital) located at _____________________________________________________________ (address), its directors, medical and surgical staff, agents, employees and any other person connected with the surgery hereafter to be performed on releasor with __________ (his or her) consent.

 

Releasor understands and agrees that:

 

1. After extensive medical testing and diagnoses, it is the opinion of the medical staff of _____________________________________ (hospital) that releasor is suffering from ___________________________________ (disease or condition) ___________ (that has arisen as a result of __________ ).

 

2. Releasor faces the possibility of death or serious disability unless surgery described generally as follows is performed without delay:  ______________________________

____________________________________________________________________

 (describe the surgery).  Releasor has been advised by ___________________________

(physician), a member of the professional staff of ______________________________

(hospital), as to the dangers associated with, and possible complications from, such surgery.

 

3. Certain resident physicians and surgeons at _________________________________ (hospital) are qualified and willing to perform the surgery.

 

4. Before such surgery will be performed, releasor must consent thereto and must release the physicians and surgeons who propose to perform the surgery, as well as ___

_____________________ (hospital) and its medical staff, agents and employees, from all liability that may result from the surgery.

 

In consideration of the surgery to be performed and any further surgery that may, in the opinion of the medical staff of _____________________________________ (hospital) be necessary, releasor, fully realizing that such surgery may be unsuccessful, that it may have certain complications, including, but not limited, to: 

___________________________________________________________________

___________________________________________________________________

_________________________________________ (enumerate possible consequences), and that possible results of such complications are _____________________________

___________________________________________________________________ _______________________________________ (enumerate), requests that such surgery be performed, and expressly consents thereto. Releasor hereby releases and forever discharges ________________________________ (hospital), its directors, medical and surgical staff, agents, employees and any other persons connected with such surgery, from all claims, damages and causes of action that may arise from the surgery herein described, and from other medical care arising therefrom, including post-surgical treatment while releasor remains a patient at ____________________ ________________ (hospital).

 

Releasor agrees that no representations have been made regarding the success of this surgery to releasor, except as set forth in this consent and release.

 

This release shall be binding on __________________________, (if appropriate:  and ___________________, the spouse of releasor,) and on the heirs, legal representatives and assigns of releasor.

 

Releasor has read all the terms of this instrument and understands that __________ (he or she) is signing a complete release and bar to any claim resulting from the surgery herein described.

 

In witness whereof, releasor has executed this release at _________________________

___________________________ (designate place of execution) on __________ (date).

 

 

_____________________________________                   _______________________

Signature                                                                               Date

 

Executed in the presence of:

 

_____________________________________________

_____________________________________________

 

_____________________________________________

_____________________________________________

(Signatures of witnesses, with names and addresses indicated for each person)

 

 

Contributed by
Anonymous4
 
Name of Firm Anonymous4
Total Forms Contributed 75
 

See All Anonymous4's Forms
 

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Terms Of Use

Submissions to this site, including any legal or business forms, posts, responses to questions or other communications by contributors are not intended as and should not be construed as legal advice. You are strongly encouraged to consult competent legal council before engaging in any action based upon content contained on this site.

These downloadable forms are only for personal use. Retransmission, redistribution, or any other commercial use is prohibited. This includes reposting forms from this site to another site offering free legal or other document forms for download.

Please note that the donator may have included different usage terms regarding this form, and you agree to abide by these terms. It is highly recommended that you have a licensed attorney review any legal documents for which you are searching in order to make sure that your needs are being properly and completely satisfied.

Your use of this site constitutes your acceptance of our terms of use and your agreement to hold this site, its officers, employees and any contributors to this site harmless for any damage you might incur from your use of any submissions contained on this site. If you do not agree to the above terms, please do not proceed.

These forms are provided to assist business owners and others in understanding important points to consider in different transactions. They are offered with the understanding that no legal advice, accounting, or other professional service is being offered by these documents or on this website. Laws vary in the different states. Agreements acceptable in one state may not be enforced the same way under the laws of another state. Also, agreements should relate specifically to the particular facts of each situation. Therefore, it is important to consult legal counsel whenever utilizing these forms. The Forms are not a substitute for legal advice YourFreeLegalForms.com is not engaged in recommending or referring members on the site or making claims about the competence, character or qualifications of its participating members.
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