RECOGNITION OF INFORMATION CONSENT LIGHTENED
NAME………………………………………
FIRST NAME…………………………………
DELIVERY DATE OF DOCUMENT ………………………
As part of my care by Dr. ………………… ..and in order to meet the legal obligations, I confirm that I have been informed orally and in an accessible language of serious risks, including vital, inherent in all surgical act.
I have been informed that there is a certain percentage of serious complications, possible sequelae and potentially life-threatening risks, which occur not only because of my condition, but also because of history and other conditions of which I am aware. I am a carrier, to unpredictable individual reactions as well as to a possible therapeutic hazard.
I was able to ask all the questions concerning this procedure to the surgeon and I took note that in addition to the risks mentioned above, there is sometimes an unpredictability of duration of the sequences, particular anatomical variations, specificities of cicatrization as well as exceptional risks. even unknown.
The expected benefits of this intervention were explained to me, with the possibility of a failure or a disappointing result, therapeutic alternatives as well as the possibility of subsequent operative recovery.
The explanations provided appeared to me to be understandable and sufficiently clear to allow me to decide to ask that this intervention be practiced by this surgeon.
I was also informed of the possibility during the intervention of unexpected discoveries requiring the performance of acts or additional examinations not initially planned. In this sense, I authorize the surgeon to perform any act that he deems necessary and to be assisted by another practitioner if necessary.
I confirm that the delay between the intervention and the consultation seemed to me sufficient. In the meantime the doctor …………………… is at my disposal to answer any questions from me or from my doctor.
In addition, I agree to go to the scheduled consultations and to submit to all the care, all the precautions or recommendations prescribed before and after the intervention.
This document does not constitute in any way a waiver of liability but an acknowledgment of information.
Date …………. / …………… / …………….
Signature (preceded by the words ‘read, approved and understood’)