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Surgery Informed Consent Form Template

Streamline Patient Understanding for Surgical Procedures

Navigating the complexities of surgical procedures can be overwhelming for both patients and providers. This Surgery Informed Consent Form Template helps you ensure patients understand the risks, benefits, and alternatives to the surgery they are considering. By using this tailored template, you can enhance patient trust, ensure legal compliance, and streamline the consent process, all while maintaining clear communication. Make informed decisions easier for your patients with this practical tool.

Use this Template (FREE) Live Preview
Patient full name
Date of birth
Primary phone number
Emergency contact full name
Emergency contact phone
Emergency contact relationship
Spouse/Partner
Parent
Child
Sibling
Friend
Caregiver
Other
Please Specify:
Procedure name or description
Treating clinician/surgeon
Planned procedure date
Body site/side
Left
Right
Bilateral
Midline/Not side-specific
Not applicable
Type of anesthesia planned
Local
Regional
Sedation
General
To be determined
Not applicable
Allergies (drug, latex, other)
Current medications and supplements (include blood thinners)
Is there any possibility you are pregnant?
Yes
No
Not applicable
Prefer not to say
Do you have any implanted devices (e.g., pacemaker, defibrillator)?
Yes
No
Do you have a history of bleeding disorders or easy bruising?
Yes
No
Have you had prior problems with anesthesia or surgery?
Yes
No
I understand the nature and purpose of the procedure.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I understand the potential risks and complications.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I understand reasonable alternatives, including no treatment.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
My questions were answered to my satisfaction.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I understand that outcomes are not guaranteed.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I understand I may refuse or withdraw consent before the procedure.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I consent to the proposed procedure.
Yes
No
I consent to the planned anesthesia.
Yes
No
If medically necessary, I consent to receive blood or blood products.
Yes
No
Not applicable to my procedure
I wish to discuss before deciding
Clinical photo and image use
Do not take photos
Photos for my medical record only
De-identified photos may be used for education or quality improvement
Both medical record and de-identified educational use
I permit qualified assistants, trainees, or observers to be present as appropriate.
Yes
No
Only essential clinical staff
I understand I am responsible for costs not covered by insurance.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I have received or had access to the Notice of Privacy Practices.
Yes
No
Not sure/Not applicable
Your role in giving consent
I am the patient
I am the parent or legal guardian
I am a legally authorized representative/agent
Other
Please Specify:
If not the patient, state your relationship to the patient
Interpreter assistance during this consent
No interpreter needed
Qualified medical interpreter assisted
Family or friend assisted at my request
Patient or authorized representative printed name
Date signed by patient/representative
Witness printed name
Witness date
Clinician obtaining consent printed name
Clinician date
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Paper art illustration depicting a surgery informed consent form with medical symbols and a pen

When to use this form

Use this template before any operation in a hospital, ASC, or clinic. It helps your team document the exact procedure, site/side, anesthesia plan, and consent for blood products. Surgeons and nurses get clear, signed authorization; patients get risks, benefits, alternatives, and pre- and post-op instructions in plain language. Use it for cases like laparoscopic appendectomy, joint repair, or lesion removal, and for urgent add-on procedures. If your practice also handles piercings or related services, you can manage those with the Body piercing consent form and capture guardian approval using the Minor piercing consent form in the same workflow. For simple office procedures, a Simple informed consent form may be enough.

Must Ask Surgery Informed Consent Questions

  1. What exact procedure, site, and side are you authorizing?

    Clear wording prevents wrong-site or wrong-procedure errors and sets shared expectations. It also anchors the rest of the consent details to a specific, documented plan.

  2. What major risks, benefits, and likely outcomes do you understand?

    Stating these in your own words confirms informed decision-making. It reduces surprises and supports ethical and legal standards.

  3. What alternatives, including no surgery, have been explained to you?

    Recording alternatives shows you weighed options and chose the path that fits your goals. It also helps clinicians tailor care if your preferences change.

  4. What medications, allergies, and health conditions could affect surgery or anesthesia?

    This safety check helps prevent reactions and guides dosing or technique changes. It can also flag when to consult specialists before proceeding.

  5. Do you consent to the planned anesthesia and, if needed, blood products?

    Separate consent for anesthesia and transfusion avoids delays in the operating room. It ensures you understand who will provide anesthesia and the key risks involved.

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