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Surgical and Extraction Consent: Consent For Operation and Anesthesia Services of Dental Clinic

This document contains consent forms for both a dental operation and anesthesia services. The operation consent section details the planned procedure, reasons for it, risks and alternatives. The doctor affirms explaining these details to the patient. The patient agrees they understand the procedure, risks of alternatives, and possible post-operation issues. The anesthesia consent similarly covers the planned type of anesthesia, risks explained, and patient's understanding and consent. Both sections require signatures of the doctor and patient to document informed consent for the planned dental work and anesthesia.

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Justin
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Available Formats
Download as PDF, TXT or read online on Scribd
44 views

Surgical and Extraction Consent: Consent For Operation and Anesthesia Services of Dental Clinic

This document contains consent forms for both a dental operation and anesthesia services. The operation consent section details the planned procedure, reasons for it, risks and alternatives. The doctor affirms explaining these details to the patient. The patient agrees they understand the procedure, risks of alternatives, and possible post-operation issues. The anesthesia consent similarly covers the planned type of anesthesia, risks explained, and patient's understanding and consent. Both sections require signatures of the doctor and patient to document informed consent for the planned dental work and anesthesia.

Uploaded by

Justin
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Consent for Operation and Anesthesia Services of Dental Clinic

＊Basic Information
Patient’s name：____ _
Patient’s date of birth：___ _ /_ / （YY/MM/DD）
Patient’s medical record number ：____ _

Surgical and extraction consent

1. Operation planned for implementation

(1) Type of illness

(2) Suggested operation

(3) Reasons for suggested operation

2. Doctor’s Statements
(1) I have, to the best of my ability, fully informed the patient about the surgery, especially the
following matters:

□Reasons for suggested surgery, surgical process and scope, risks and success rate, and the
possibility of blood loss
□Possible complications and treatments for the complications
□Consequences of not operating and alternative treatments
□Short-term or long-term conditions that might be expected after the surgery
□Other information related to operation explanation has been delivered to the patient
(2) I have given the patient sufficient time to ask questions regarding the surgery and answered
them as such:

1
Chief operating surgeon
Name ：
Signature ：
Date / / (YY/MM/DD)
Time: hour minute
3. Patient’s Statements
(1) The doctor has explained and I understand the necessity, process, risks, success rate, and other
information regarding the operation.
(2) The doctor has explained and I understand the risk of choosing other possible treatments.
(3) The doctor has explained and I understand the possible situations that might occur after the
surgery and the risks of not undergoing surgery.

(4) I understand there might be blood loss at crucial times. I □consent □do not consent to a blood
transfusion.
(5) Based on my situation, proceeding of operation and treatment method etc., I have proposed
questions and doubts to the physician and been explained to.
(6) I understand that during the surgical process, if it is necessary to remove certain organs or
tissues to aid with treatment, the hospital will preserve it for a duration of time to study and
judiciously dispose of at a later date.
(7) I understand that this operation has certain risks and cannot guarantee to certainly improve
my state of illness.
(8) I have obtained other instructions related to surgery delivered by the physician.

(Firmar)

Sign

2
Consent for Anesthesia Services
1. Type of Anesthesia to be Administered (if the medical term is unclear, please add a concise
explanation)

Name of operation to be implemented by physician：﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍


□Caries removal and dental restoration
□Simple odontotomy
□Complex odontotomy
□Other ： ﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍

2. Suggested method of anesthesia：


□Local anesthesia
□Sedation
□General anesthesia
□Other：﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍﹍
3. Physician’s Statement
(1) I have already carried out a preoperative anesthesia assessment for this patient.
(2) I have already done my best to explain to the patient in a manner that he/she can understand all
information relevant to the anesthesia process, in particular the following items:

□The steps of the anesthesia


□The risks involved in the anesthesia
□Possible post-anesthesia symptoms
□Other information related to anesthetization explanation has been delivered to the patient.
。
(3) I have provided the patient with sufficient time to ask the following questions in relation to the
anesthesia process of this operation, and have provided the patient with answers:

3
Physician's signature：
Date: / / (YYYY/MM/DD)
Time: : （

4. Patient’s Statement
(1) I understand that for the successful completion of this operation, I must undergo anesthesia to
alleviate the pain and fear caused by the operation.
(2) Physician has made explanation to me, and I have understood the method and risk of
anesthetization.
(3) I have understood the side effects and complications might occur in anesthesia.
(4) I have asked the physician questions and fears in relation to the operation and have been
explained.

Based on the above statement, I hereby agree to receive such operation and anesthetization.
Name of consent：
Signed by：
Relationship to patient:

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