my request and consent to surgery or other procedures

HENRY FORDMACOMB HOSPITALSFORM #: HFMH-24-0277MR-1211CHART TAB: CONSENTPatient Name___________________________________Date of Birth ___________________________________CONSENT TO MEDICAL, SURGERY OR DIAGNOSTIC PROCEDURESThe planned procedure(s) is/are: ____________________________________________________________________________________________________________________________________________The procedure will be performed by:______________________________________________________My doctor has explained why this procedure(s) is recommended for me and the benefits that I may anticipate. Mydoctor further explained that there are risks involved in the procedure(s) which can be very serious and what otheralternative procedures or treatments may be available to me if I do not have this procedure.I have opted to have the procedure listed above. I am requesting and giving my consent to the procedure(s) listedabove being done by my doctor and other healthcare personnel as appropriate. I also have discussed the risks ofanesthesia with the anesthesiologist or his/her designate and I agree to the use of anesthesia and/or sedation if it isdeemed appropriate.My doctor can have other doctors (including resident doctors) assist or do part of the procedure(s) or have anotherdoctor take his/her place during the procedure(s) as appropriate to their level of skill and training. I understandthat this hospital is a teaching institution and that I agree that students may take part in my procedure(s) for thepurpose of advancing medical education. I also give my consent to the nurses and technical people at the hospitalto do what they would usually do for the procedure(s) that I am having.I know that medical science is not perfect and many things are not predictable. I know the doctor may findsomething he/she did not expect. If an unexpected condition exists, the doctors involved can use their medicaljudgment and change the procedure(s) as appropriate.I know it is up to me to tell the doctor about allergies I have, drugs or medicine I have taken, when I have eaten ordrank alcohol, any drugs or medicine I should not have and any other health problems I have. I also understand itis important to my health and safety that I follow the advice in any information sheets, pamphlets or doctors’instructions, before and after the procedure(s).I know my doctor, like most other doctors, may not be a hospital employee.SAMPLEI know that specimens and tissues may be taken from my body during the procedure(s) and may be disposed of bythe hospital. I give permission that the specimens and tissues can be used for scientific reasons or in any way thedoctors and the hospital deem appropriate.I agree that the doctor and the hospital can photograph or videotape parts of my body during the procedure(s) forscience and teaching purposes. Unless I give permission or as required by law, my identity will not be revealed inthe pictures or statements describing the pictures. For the purpose of advancing medical education, I consent tohaving observers in the operating room or patient room. This may include representatives from pharmaceuticalcompanies and/or device manufacturers.I know I could lose blood. If this happens, I may need blood or products made from blood. I am aware that it ispossible that certain diseases can be transmitted through blood and blood products. I give consent to receive any necessary blood products _________Patient Initials I DO NOT want to receive any blood or blood products. I accept all risks including death. _________Patient Initials(Page 1 of 2)

HENRY FORDMACOMB HOSPITALSPatient Name____________________________Date of Birth____________________________CONSENT TO MEDICAL/SURGERY OR DIAGNOSTIC PROCEDURES continuesMy doctor has answered all of my questions to my satisfaction. I understand that if I have more questions, Ishould ask them before the procedure(s) and my doctor will answer them. I have read (or have had read to me)both sides of this form and I understand it. I request and give my consent to having the procedure(s) listed above. N/A Surgical/Procedure Site Infection Prevention Education Provided ________________________ N/A Central Line Infection Prevention Education Provided ________________________________________________________________________ _________________ ___________Signature of Patient/Representative Date Time_______________________________________Relationship to Patient_____________________________________Reason Patient is unable to sign for him/herself_______________________________________ _________________ ___________Witness (If Telephone Consent) Date TimeI have fully explained the procedure(s), with associated risks, benefits and alternatives, to the patient'ssatisfaction. The patient expresses his/her desire to proceed with the procedure(s) and plan as indicated above._______________________________________ _________________ ___________Signature of Physician/Provider Date TimeUNIVERSAL PROTOCOL VERIFICATION(FOR NON-OPERATING ROOM SETTINGS)1. Patient Identification-verification of correct patient (name,MRN & date of birth), correct procedure, correct site, withpatient awake and aware, if possible.2. Documentation: Consent accurately completed and signedby the licensed, credentialed practitioner performing theprocedure. History & physical, nursing assessment, correctdiagnostic & radiology test results, appropriately labeled anddisplayed.3. All required implants, devices, and/or special equipmentneeded for procedure are available. Safety precautions basedon patient’s history or medication use have been addressed.4. All required blood products, antibiotic or fluids forirrigation needed for procedure.5. Site marking – when laterality involved, must be initialed bylicensed, credentialed practitioner performing the procedure,using a permanent marker and visible after draping.(Thoracentesis, Chest Tube Insertion, Joint Aspirations)6. TIMEOUT – initiated while all activities suspended, all teammembers focused, and verbally in agreement to correct patient,correct procedure, and correct site.(A separate timeout is required for each procedure.)Pre-ProceduralVerification(Initials/Time)Nurse orPhysicianInitials(for Time Out)RN SignatureRN SignatureDate Time N/ASAMPLENurse or Physician Signature: Date TimeFORM #: HFMH-24-0277MR-1211CHART TAB: CONSENT(Page 2 of 2)