Surgery Consent Form

First Name
Last Name


In addition, I consent to the administration of anesthesia by an Anesthesiologist, Certified Registered Nurse Anesthetist (CRNA), and/or Surgeon or his/her associates. I have had the opportunity to ask questions, and these were answered to my satisfaction. I understand that common complications of anesthesia may include nausea, vomiting, headache, numbness, or tingling. More serious but rare complications include heart and lung problems, heart attack, stroke, and death. My vital signs, including electrocardiogram, blood pressure, oxygen saturation and breathing, temperature, and level of consciousness, will be monitored continually to help ensure my safety. I realize that anesthesia may have to be changed possibly without explanation to me.

The nature and purpose of the operation, possible alternative methods of treatment, the risks involved, and the possibilities of complications have been fully explained to me. No guarantee or assurance has been given by anyone as to the results that may be obtained.

I consent to the performance of operations and procedures in addition to or different from those now listed, which may be considered necessary or advisable in the course of the operation.

I consent to photographing or televising of the operations or procedures to be performed, including appropriate portions of my body, for medical, scientific, or educational purposes, provided my identity is not revealed by the pictures or by the descriptive texts accompanying them.

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

I consent to the disposal by Valley Surgery Center of any tissues or parts which may be removed.

In checking the box below I acknowledge:

The Valley Surgery Center does not honor advanced directives including living wills.

I have received a copy of the ""Patient's Rights & Responsibilities"" and of this consent form. I have been informed of my right to change "Specialty Physicians"

I have been informed of my right to be referred to a payment counselor for service fees or payment policies. I have read this informed consent (or it has been read to me) and I fully understand it and the possible risks, complications, and benefits that can result from the surgery.