Surgery Consent Form

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Admission Time *

Hour

Minute

Second

AM PM

Procedure(s) Name(s) *

Hysteroscopy

Laparoscopy

Hysterectomy

Myomectomy

Hysteroscopic Resection of Fibroids

Oophorectomy

Ovarian Cystectomy

Endometriosis Treatment

Laparoscopic Transabdominal Cerclage

Endometrial Ablation

Contact Person *

First Name

Last Name

Patient's Parent/Guardian

If Applicable

First Name

Last Name

Parent/Guardian's Contact Details

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Declaration by the Patient or Guardian *

I consent to the admission to the hospital and procedure(s) indicated above

I understand that the administration of medicine and anaesthetic may be needed in association with the admission/procedure and that these may carry risks.

I understand that the hospital staff administer care under the treating doctor's direction, or in an emergency, medical and nursing care is administered as required, including the administration of blood and blood products.

I understand that I may withdraw any consents given by me at any time before operation.

I acknowledge that the medical practitioner has explained why I need treatment.

I acknowledge the risks and benefits of receiving the treatment have all been discussed.

I acknowledge that I have had the opportunity to ask questions and any questions have been answered in a way that I understand.

Name *

First Name

Last Name

Name *

First Name

Last Name

Declaration by the Patient or Guardian *

I understand that my surgeon's estimate fees do not include the hospital charges and services provided by other doctors, surgical assistants, anaesthetist, radiologist, pathologist and etc.

I declare I am responsible for any amount payable regarding the above procedure.

I understand that payment needs to be processed before the date of the surgery.

I understand there might be extra costs in the case of unforeseen circumstances during my admission to hospital.

I acknowledge that it is my responsibility to confirm with the health fund that I am covered for the procedure above.

I acknowledge that I have been advised that other health professionals may be involved in my treatment and that the surgeon's estimate does not include their fees and charges unless specifically stated otherwise.

Name *

First Name

Last Name