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Phone: 301-631-3881
Fax: 301-631-3883

Consent for Operation

Consent for Operation, Anesthesia, or Other Procedures

I authorize Dr…. and/or Dr. … to provide treatment and perform the following operation(s) or procedure(s) of:

We will list your procedure(s)

1. If, in the course of the operation or procedure, unforeseen conditions arise that warrant the need for additional or different surgery or procedures from those now contemplated, I consent to additional operation(s) or procedure(s).

2. I authorize listed qualified medical practitioners, who are not physicians, to perform parts of the above listed surgery with the surgeon or administer the anesthesia, if they are permitted to do so under the laws of this state. Such practitioners will only perform tasks within their scope of practice for which they have been granted privileges by the Thomas Johnson Surgery Center.

We will list your Practitioner(s) and their tasks.

3. I understand that I am required to have a companion over the age of 18 years old accompany me to the Center and be available during and after my surgery and that I will be discharged to that person’s custody and must rely on him or her for my return home.

You will be asked to list a companion and their contact info, giving them authorization to discuss your medical/billing information with support services at the center.

5. I agree an observer or clinical or technical representative(s) may be present for my procedure at my physician’s direction. I consent to photographing, video-taping, or televising of the operation(s) or procedure(s) showing parts of my body for medical, scientific, or educational purposes, providing my identity is not revealed.

6. I consent to any disposal of any tissues or body parts that may be removed during the operation(s) or procedure(s). (Disposal is mandated by Facility Policy & Procedure.

7. I understand that I have the right to choose my physician, my treatment(s) and subsequent place for treatment(s) as recommended by my physician. I make these decisions independently to be treated at Thomas Johnson Surgery Center. I understand that my physician may or does have ownership interest in this facility.

8. In the event that the physician or staff is exposed to my blood, body fluids or contaminated materials, I agree to allow testing that will determine the presence of HIV or Hepatitis. An accredited laboratory, at no cost to me, will perform all required tests.

Please understand that Advanced Directives are not honored at this facility and that in the event of an emergency or life threatening situation, advance cardiac life support procedures will be instituted in every instance and I will be transferred to a higher level of care.

Proceed to Assignment of Benefits Form