Obstetrical Delivery Consent Form - Valley Hospital

(ii) In connection with my consent to transfusion(s) of blood, my Doctor has provided me with informationabout, and has discussed and explained the following:(a) The reason(s) for transfusion(s), a description of the transfusion(s), the benefits and significant risks ofthe transfusion(s), all alternatives including autologous, homologous and directed donation, as well as therisks and consequences of not receiving a transfusion(s).(b) That a blood transfusion is not always successful and that no guarantee or assurance has been made to meor anyone concerning the results of a transfusion, and that I may be subject to ill effects as a result ofreceiving blood and/or blood products.(c) That this consent applies to all transfusions I may receive during this hospitalization.6. Anesthesia. I have received and have read the Patient Information Sheet on Anesthesia and I consent to theadministration and management of such anesthesia as the anesthesiologist assigned to my procedure(s) deemsappropriate. I have also received and have read the Patient Information Sheet on Conscious Sedation and Iunderstand that conscious sedation may be administered by a doctor other than an anesthesiologist, or by anurse under the direction of a doctor, and I consent to the administration and management of such conscioussedation as the doctor deems appropriate. I have been informed of the risks most commonly associated withthe administration of anesthesia and conscious sedation. I am aware that complications from all forms ofanesthesia and conscious sedation are rare, but may occur.7. Specimen. I further consent to the examination and disposal of any specimen(s) removed in the performanceof the procedure(s), as well as for the use of any specimen(s) for the advancement of medical science andeducation at the Hospital or any other institution the Hospital may designate.8. Disposal of Umbilical Cord and Placenta. I consent to the hospital's disposal of the umbilical cord andplacenta, as it sees fit.9. Certification. By my signature below, I certify the following to be true:A. I have read and fully understand the information in this consent form.B. The information referred to in this consent form was explained to me.C. I have had enough time to discuss my condition and the procedure(s), including blood transfusions andanesthesia, with my Doctor, his/her associate or designee.D. All of my questions have been answered to my satisfaction.E. I believe I know enough about the procedure(s), blood transfusions and anesthesia, and do hereby give myconsent for surgery or special procedures.(Signature of Patient)_____________________________________(Witness to Signature(s))_____________________________________The above Procedures Have Been Fully Explained tothe Concerned Parties (Signature(s) of Physician(s))Consent Includes:Pt. Info. Sheet – Labor & Delivery - given to patient not part of permanent recordIC-42 MRec Page 2 of 7Pt. Info. Sheet – Transfusions – given to patient not part of permanent record04/02, 04/03, 02/04, 02/06Pt. Info. Sheet – Anesthesia - given to patient not part of permanent recordPt. Info. Sheet – Conscious Sedation - given to patient not part of permanent record