Surgery Consent Form

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The surgery consent form is used to indicate that a patient receiving surgery or special procedures has been made aware of the nature of the operation, the risks involved, the required medication/anesthesia, and any other pertinent information that may effect their decision to consent. The patient must sign off taht they ahve had ample opportunity to field any questions they need answered and to address any concerns they might have going into the operation. The signature indicates that they believe they have enough information to classify their decision to have the operation as informed.

How to Write

Step 1 – Download in Adobe PDF.


Step 2 – The name of the patient and the name of the practitioner should be entered first. The surgery should be described and named by the practitioner in the paragraph field.

Step 3 – The patient may indicate whether or not the consent to receiving blood transfusions. If they do not consent, they must initial indicating that they understand that refusing blood transfusions may be dangerous and that they will be offered registration in the “Blood Alternative Program.”

Step 4 – The entire document should be read thoroughly by the patient and preferably by the patient’s attorney. The representative of the patient or the patient themselves will need to sign the document, and provide the date and time of their signature.

Step 5 – If the patient is unable to consent, their representative will be required to complete this section. The following must be supplied:

  • Name of patient’s authorized representative
  • Relationship to the patient
  • Signature/date/time
  • Reason consent can be provided
  • Name of witness
  • Witness signature

Step 6 – The practitioner must sing the form as well along with the date and time of their signature.