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Form #1048Consent to Surgery and Release
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Consent to Surgery and Release Free Legal Form
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CONSENT TO SURGERY AND RELEASE
Consent and
release executed by _____________________________________ (name), of
___________________________________________________________ (address), as
releasor, to __________________________________________ (hospital) located at
_____________________________________________________________ (address), 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 _____________________________________ (hospital) that releasor is suffering
from ___________________________________ (disease or condition) ___________
(that has arisen as a result of __________ ).
2. Releasor
faces the possibility of death or serious disability unless surgery described
generally as follows is performed without delay:Â
______________________________
____________________________________________________________________
 (describe the
surgery). Releasor has been advised by ___________________________
(physician), a
member of the professional staff of ______________________________
(hospital), as
to the dangers associated with, and possible complications from, such surgery.
3. Certain resident
physicians and surgeons at _________________________________ (hospital) are
qualified and willing to perform the surgery.
Â
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 ___
_____________________
(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 _____________________________________
(hospital) be necessary, releasor, fully realizing that such surgery may be
unsuccessful, that it may have certain complications, including, but not
limited, to:Â
___________________________________________________________________
___________________________________________________________________
_________________________________________
(enumerate possible consequences), and that possible results of such
complications are _____________________________
___________________________________________________________________
_______________________________________ (enumerate), requests that such surgery
be performed, and expressly consents thereto. Releasor hereby releases and
forever discharges ________________________________ (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 ____________________ ________________ (hospital).
Â
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.
Â
This release
shall be binding on __________________________, (if appropriate:Â and
___________________, 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 _________________________
___________________________
(designate place of execution) on __________ (date).
_____________________________________Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â _______________________
Signature                                                                              Date
Executed in
the presence of:
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
(Signatures
of witnesses, with names and addresses indicated for each person)
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regading how we deal with your email. We pledge that we will:
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Submissions to this site, including any legal or business forms, posts, responses
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not be construed as legal advice. You are strongly encouraged to consult competent
legal council before engaging in any action based upon content contained on this
site.
These downloadable forms are only for personal use. Retransmission, redistribution,
or any other commercial use is prohibited. This includes reposting forms from this
site to another site offering free legal or other document forms for download.
Please note that the donator may have included different usage terms regarding this
form, and you agree to abide by these terms. It is highly recommended that you have
a licensed attorney review any legal documents for which you are searching in order
to make sure that your needs are being properly and completely satisfied.
Your use of this site constitutes your acceptance of our terms of use and your agreement
to hold this site, its officers, employees and any contributors to this site harmless
for any damage you might incur from your use of any submissions contained on this
site. If you do not agree to the above terms, please do not proceed.
These forms are provided to assist business owners and others in understanding important
points to consider in different transactions. They are offered with the understanding
that no legal advice, accounting, or other professional service is being offered
by these documents or on this website. Laws vary in the different states. Agreements
acceptable in one state may not be enforced the same way under the laws of another
state. Also, agreements should relate specifically to the particular facts of each
situation. Therefore, it is important to consult legal counsel whenever utilizing
these forms. The Forms are not a substitute for legal advice YourFreeLegalForms.com
is not engaged in recommending or referring members on the site or making claims
about the competence, character or qualifications of its participating members.
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