1.) I authorize the performance upon--------------------of the following operation------------- to be performed by Dr. --------- and assisted by ---------------PA-C
2.) The following has been explained to me by Dr. ------:
a.) The nature and purpose of the operation--------------------------
b.) The possible alternative methods of treatment-------------------
c.) Some risks, complications and possible consequences---------------------
3.) I understand that the explanation that I have received is not exhaustive and that other more remote risks, complications, consequences may arise. I have been advised that if I desire a more detailed and complete explanation of any of the forgoing, such information will be given to me. I do not request such explanation.
4.) Additionally, I consent to the performance of operations and procedures in addition to or different from those now contemplated, whether or not arising from presently unforeseen conditions which the above doctor or his associates may consider necessary or advisable during the course of the operation. Under no circumstances, however, do I consent to ----------------------------.
5.) I acknowledge that I have received no warranties or assurances with respect to the benefits to be realized or consequences of the aforementioned procedure.
6.) I acknowledge that I have read this document in its entirety and that I fully understand it and that all blank spaces have either been completed or crossed off prior to my signing.
Signature of Patient Date---------
Signature of relative if pt. unable to sign--------------Date----------
Witness-----------------------
I hereby certify that, to the best of my ability, I have explained the nature, purpose, benefits, reasonable risks, of and alternatives to, the proposed procedure/operation, have offered to answer any questions and have answered such questions. I believe that the patient/relative/guardian fully understands what I have explained and answered.
Dr.-----------------
Robert M. Blumm has received national recognition as a distinguished fellow of the American Academy of Physician Assistants (AAPA). He is the past president of the Association of Plastic Surgery Physician Assistants, and was past-president of the American Association of Surgical Physician Assistants, past president of the American College of Clinicians and NYSSPA, as well as Chairman of the Surgical Congress of the AAPA. In addition, Bob received the John Kirklin MD Award for Professional Excellence from the American Association of Surgical Physician Assistants. Along with his associate, Dr. Acker, Bob was the first recipient of the AAPA PAragon Physician-PA Partnership Award. He has been a contributing author of three textbooks, written 300 plus articles and is a sought out conference speaker throughout the United States.
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
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