[Ortho] согласие на операцию эндопротезирования тазобедренного сустава

[Dr. A. Liberson]

I have a general one

Operation Consent Form



Name of the patient:                                          / 
/                               /

                                          Surname                     Given 
name            Name of father    Identity number



After having received a detailed oral explanation from Dr. 
/

                                                                             
                                                    Surname 
Given name



regarding the need for undergoing an operation:

including the intended results, the reasonable risks and the alternate 
possible modes of treatment in the circumstances at hand, including the 
chances and risks involved in each of these procedures, and the tests and 
treatments involved therein, I hereby give my consent to performing the 
aforementioned operation in the hospital (hereinafter - the Principal 
Operation).



It has been explained to me and I understand that there is a possibility 
that during the course of the Principal Operation, it will become necessary 
to expand its scope, modify it or take other or additional steps, including 
additional surgical procedures that cannot be anticipated fully or with 
certainty, but whose meaning has been clarified to me. Therefore I also 
agree to any such expansion, modification or execution of other or 
additional procedures, including operations that in the opinion of the 
physicians of the hospital will be vital or required during the Principal 
Operation.



My consent is also given for performing anesthesia, whether general or 
local, if necessitated, at the discretion of the attending physicians, other 
than



(Please indicate details, and if there are none, please state "none")



I am aware and agree that the operation and all the other procedures be 
performed by the parties charged with doing so, in accordance with the 
procedures and instructions of the hospital, and that it has not been 
guaranteed to me that these will be performed, in part or in full, by a 
certain person, provided that they are done with the customary 
responsibility of the hospital and subject to the law, and that the person 
responsible for the operation will be:



**                                                           / 
/                               /

Name of physician              Date                      Time 
Signature of patient



                                                                /

Name of \ guardian                             Signature of guardian (in the 
case of a legally incapacitated, minor or mental patient)



I confirm that I have explained orally to the patient / guardian of the 
patient - all the foregoing to the required level of detail and that he has 
signed the consent before me, once I was convinced that my explanations have 
been fully understood thereby.



Name and signature of physician 
License number



----- Original Message ----- 
From: "Maxim Agalakov" <orthoforum на weborto.net>
To: <ortho на weborto.net>
Sent: Wednesday, August 20, 2008 8:10 PM
Subject: [Ortho] согласие на операцию эндопротезирования тазобедренного 
сустава


> Уважаемые коллеги, многие из вас сталкивались с согласием на
> операцию. Интересует согласие на эндопротезирование т/б, включая
> возможные осложненмя (собственные или переведенные - рус/англ, если у
> кого есть- выложите пожалуйста/ Заранее благодарен, Максим
>
>
>
> _______________________________________________
> Ortho mailing list
> Ortho на weborto.net
> http://weborto.net:8080/mailman/listinfo/ortho
>


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