Cardiac Surgery Treatment Agreement and Informed Consent

Patient Information

Name: _________________________
Date of Birth: __________________
Medical Record #: _______________

Procedure Information

Proposed Surgery: _______________________________________________
Surgeon: ____________________________________________________
Date of Surgery: _____________________________________________

1. Consent to Treatment

I hereby authorize Dr. _________________ and associates to perform the cardiac surgical procedure specified above. I understand this procedure will be performed under general anesthesia.

2. Nature of Procedure

The following has been explained to me in detail:

• The nature and purpose of the procedure
• Alternative treatment options
• Expected benefits
• Possible complications and risks
• Recovery process and timeline

3. Acknowledgment of Risks

I understand that this cardiac surgery carries certain risks, including but not limited to:

• Bleeding and need for blood transfusion
• Infection
• Stroke or neurological complications
• Heart rhythm abnormalities
• Kidney dysfunction
• Respiratory complications
• Death in rare circumstances

4. Additional Procedures

I authorize the performance of additional procedures that may be deemed necessary during the course of the planned surgery if medical circumstances require them.

5. Blood Products

□ I accept blood products if needed
□ I decline blood products (separate form required)

6. Teaching Institution Statement

I understand that this facility is a teaching institution and qualified medical personnel in training may participate in my care under appropriate supervision.

Signatures

Patient/Legal Guardian: _________________________ Date: __________

Witness: _____________________________________ Date: __________

Physician: ____________________________________ Date: __________

Interpreter (if applicable)

Name: _______________________________________ Date: __________