Surgical consent form template

What is on the form

• Practice details, reference and date
• Patient: name, date of birth and MRN
• Procedure or treatment, and anaesthesia
• What was explained: intended benefits, alternatives including no treatment, what the procedure involves, anaesthesia and its risks
• Material, serious or frequently occurring risks
• Clinician's signature, printed name and Irish Medical Council number
• Optional consents: photography for the medical record, blood transfusion if clinically required
• Patient's signature and date
• Notes on capacity, decision support, interpreter or advocate, and confirmation on the day

Using it well

• Your hospital's consent policy and your indemnifier's guidance govern the process; this form is a starting point, not a substitute for either.
• Consent is the discussion; record the risks you actually discussed with this patient.
• Confirm consent again on the day of the procedure, and note it.