Consent and release executed by _____________ (name), of ______________ (address), as releasor, to ____________ (hospital) located at _______________ (address), its directors, medical and surgical staff, agents, employees and any other person connected with the surgery hereafter to be performed on releasor with __________ (his or her) consent.
Releasor understands and agrees that:
1. After extensive medical testing and diagnoses, it is the opinion of the medical staff of _____________ (hospital) that releasor is suffering from _____________ (disease or condition) ___________ (that has arisen as a result of __________ ).
2. Releasor faces the possibility of death or serious disability unless surgery described generally as follows is performed without delay:
(describe the surgery). Releasor has been advised by ______________.
(physician), a member of the professional staff of _________________.
(hospital), as to the dangers associated with, and possible complications from, such surgery.
3. Certain resident physicians and surgeons at _______________ (hospital) are qualified and willing to perform the surgery.
4. Before such surgery will be performed, releasor must consent thereto and must release the physicians and surgeons who propose to perform the surgery, as well as ________ (hospital) and its medical staff, agents and employees, from all liability that may result from the surgery.
In consideration of the surgery to be performed and any further surgery that may, in the opinion of the medical staff of ___________ (hospital) be necessary, releasor, fully realizing that such surgery may be unsuccessful, that it may have certain complications, including, but not limited, to:
_________ (enumerate possible consequences), and that possible results of such complications are _________ (enumerate), requests that such surgery be performed, and expressly consents thereto. Releasor hereby releases and forever discharges _________________ (hospital), its directors, medical and surgical staff, agents, employees and any other persons connected with such surgery, from all claims, damages and causes of action that may arise from the surgery herein described, and from other medical care arising therefrom, including post-surgical treatment while releasor remains a patient at _________ (hospital).
Releasor agrees that no representations have been made regarding the success of this surgery to releasor, except as set forth in this consent and release.
This release shall be binding on ___________, (if appropriate: and ____________, the spouse of releasor,) and on the heirs, legal representatives and assigns of releasor.
Releasor has read all the terms of this instrument and understands that __________ (he or she) is signing a complete release and bar to any claim resulting from the surgery herein described.
In witness whereof, releasor has executed this release at _________ (designate place of execution) on ______ (date).
Executed in the presence of:
(Signatures of witnesses, with names and addresses indicated for each person)