The Consent For Surgery Form is a vital document required by Philippine healthcare regulations before any surgical procedure can be performed. This document is mandated by various Philippine healthcare laws, including the Medical Act of 1959 and the Universal Health Care Act, and must be completed prior to any non-emergency surgical intervention. The form serves multiple purposes: it documents the patient's voluntary agreement to undergo surgery, demonstrates that the healthcare provider has explained all relevant aspects of the procedure, and provides legal protection for both parties. The document includes detailed information about the specific surgical procedure, potential risks and complications, expected benefits, alternative treatments, and the type of anesthesia to be used. It must be completed in a language the patient understands, with provisions for interpretation services when necessary.
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1. Patient Information: Patient's complete identification details including name, date of birth, address, contact information, and medical record number
2. Healthcare Provider Information: Details of the surgeon, medical team, and healthcare facility
3. Procedure Details: Specific name and description of the surgical procedure in both medical and lay terms
4. Nature of the Procedure: Detailed explanation of what the surgery involves and its purpose
5. Risks and Complications: Comprehensive list of potential risks, complications, and side effects
6. Benefits and Alternative Treatments: Expected benefits of the surgery and available alternative treatment options
7. Anesthesia Consent: Information about type of anesthesia to be used and associated risks
8. Patient Acknowledgment: Statement confirming patient understanding and voluntary consent
9. Signature Section: Areas for signatures of patient/guardian, surgeon, witness, and date
1. Interpreter Declaration: Required when patient needs language interpretation services
2. Guardian/Legal Representative: Required for minors or patients unable to provide consent
3. Emergency Provisions: For cases where additional urgent procedures may become necessary during surgery
4. Blood Transfusion Consent: Required when blood transfusion might be needed during surgery
5. Photography Consent: For permission to photograph/record procedure for medical documentation or education
6. Religious/Cultural Considerations: When specific religious or cultural factors need to be acknowledged
7. Research Participation: When the surgery is part of a research study or clinical trial
1. Procedure-Specific Risks: Detailed list of risks specific to the particular surgical procedure
2. Pre-operative Instructions: Detailed instructions for patient preparation before surgery
3. Post-operative Care Guide: Instructions for post-surgery care and recovery
4. Medical Illustrations: Diagrams or images explaining the surgical procedure
5. Medication List: List of medications to stop/continue before surgery
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Operating Room Supervisor
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