Surgical Consent
Please complete the information.
1. Personal information
Ime
Prezime
Date of birth
Contact phone
2. Procedure information
Name of surgical procedure
Indication (reason for the procedure)
Type of anesthesia
Local
Sedation
General
Medication allergies?
Yes
No
Please list allergies
3. Voluntary Patient Consent
The patient has been given a detailed explanation of the nature, purpose, course and possible complications of the proposed surgical intervention, as well as alternative treatment methods. The patient had the opportunity to ask questions and received satisfactory answers. The patient voluntarily and without coercion consents to the described surgical intervention.
I am aware of the risks and possible complications of the procedure
I agree with the stated terms and voluntarily consent to the procedure
Patient signature
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