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Consent To Surgery And Release
CONSENT TO SURGERY AND RELEASE
Consent and release executed by [Name of Releasor], of [Address of Releasor], as releasor, to [Name of Hospital] located at [Address of Hospital], its directors, medical and surgical staff, agents, employees and any other person connected with the surgery hereafter to be performed on releasor with [his or her] consent.
Releasor understands and agrees that:
1. After extensive medical testing and diagnoses, it is the opinion of the medical staff of [Name of Hospital] that releasor is suffering from [Disease or condition], that has arisen as a result of [Reason for condition].
2. Releasor faces the possibility of death or serious disability unless surgery described generally as follows is performed without delay:
[Description of the surgery]. Releasor has been advised by
[Name of Physician], a member of the professional staff of
[Name of Hospital], as to the dangers associated with, and possible complications from, such surgery.
3. Certain resident physicians and surgeons at [Name of Hospital] are qualified and willing to perform the surgery.
4. Before such surgery will be performed, releasor must consent thereto and must release the physicians and surgeons who propose to perform the surgery, as well as [Name of Hospital] and its medical staff, agents and employees, from all liability that may result from the surgery.
In consideration of the surgery to be performed and any further surgery that may, in the opinion of the medical staff of [Name of Hospital] be necessary, releasor, fully realizing that such surgery may be unsuccessful, that it may have certain complications, including, but not limited, to:
[Possible consequences], and that possible results of such complications are [Possible complications], requests that such surgery be performed, and expressly consents thereto. Releasor hereby releases and forever discharges [Name of Hospital], its directors, medical and surgical staff, agents, employees and any other persons connected with such surgery, from all claims, damages and causes of action that may arise from the surgery herein described, and from other medical care arising therefrom, including post-surgical treatment while releasor remains a patient at [Name of Hospital].
Releasor agrees that no representations have been made regarding the success of this surgery to releasor, except as set forth in this consent and release.
This release shall be binding on [Name of Releasor], and [Spouse of Releasor], the spouse of releasor, and on the heirs, legal representatives and assigns of releasor.
Releasor has read all the terms of this instrument and understands that [he or she] is signing a complete release and bar to any claim resulting from the surgery herein described.
In witness whereof, releasor has executed this release at [Designated place of execution] on [Date of execution].
Signature Date
Executed in the presence of: [Name of Witness]
[Signatures of witnesses, with names and addresses indicated for each person]