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Informed Consent!
This document has been added to these pages for anyone considering or needing surgery. It can be ammended for man or woman and any type of surgery! Take control of your life now! All credit goes to: Eileen Marie Wayne, M.D. I want ... ____ to receive and keep my informed consent material in written and in audiotape or audiovideotape form. ____ a copy of the American Board of [My Required Specialty e.g., Plastic Surgeons] Surgical Criteria for my proposed procedure and all alternative procedures. ____ to see a videotape of my proposed procedure in its entirety as performed by my surgeon. ____ to talk with a person who has my same condition and has had my proposed treatment. ____ to share experiences with someone who has my condition and needs the procedure I had. ____ the name and address of the support groups concerning my condition. ____ a person of my choice with me at all times during my appointments and procedures including surgery. I empower my person to halt any procedure not fully explained, not authorized, or not smoothly performed. ____ a copy of my history and physical examination findings, and my Practitioner's proposed plan of action in lay and in CPT computer terminology, risks and benefits before I sign my legal consent document. ____ my right or left body part labeled "CUT" in ink before I sign my legal consent document. ____ the descriptive product package insert and full product disclosure information for any implants that are to be permanently placed into my body and for any oral and injected medications I am to receive. ____ only positive statements and healing messages said during my procedure, even though I am unconscious. ____ first right to examine and keep any and all implants and tissue removed from my body. ____ a duplicate set of glass pathology slides of my condition to keep. ____ a duplicate of my x-ray pictures and will pay the extra charge. ____ the radiologist to explain the pictures to me and will pay the extra charge. ____ copies of my typewritten test results. ____ every office and hospital encounter audiotaped -- I will bring my own audiotape recorder and audiotape. ____ my Legal Living Will and Advanced Directives honored. ____ to sign any Do Not Resucitate or Resucitate orders, Intubate orders, or abnormal feeding orders. ____ adequate medication, with self-administered pump so I will never be in pain. ____ a copy of my medical record in its entirety immediately upon request and upon completion of this visit or confinement. I reserve the right to question, correct, and sign approval of my medical record before I authorize release of any information and before it becomes a permanent, public, legal document. I will do so within 30 days. I want my original record given to me, rather than destroyed, when the facility converts to alternative record storage media. If I should die before receiving my records, provide my next-of-kin my entire medical record. ____ all my patient rights as listed by state and federal law, by the American and my State Hospital Associations. ____ only Providers I choose in writing may treat me and I reserve the right to terminate my Provider relationship at any time. ____ proof that each of my practitioners is free of AIDS and other infectious diseases. ____ redress, within 10 working days of my written grievance, for each and every violation of my orders. I send copies of my grievances to my Practitioner, my facility president, my insurance company, my State and my County Medical Society, the American Medical Association, my State Professional Licensing and Disciplinary Board, the National Institute of Health, The Better Business Bureau, Civil Rights (public accommodations division) Commission, City and State. ____ I refuse to allow anyone, not even my Provider, to give consent for me to receive any non-life-threatening procedure while I am rendered unconscious. ____ I reserve the right to refuse medication or treatment and request an AMA form (Against Medical Advice, Against My Advice, Against Mother's Advice) to document my refusals. ____ If I am unable to get urgent professional help during a
hospitalization, I'll dial 0 for the hospital operator to page the Administrator,
Supervisor, and Physician on duty 24 hours and 365 days a year, or I'll dial 911. For less
urgent matters, I request a daytime patient advocate and that an "incident"
report be filed. So that I may see, hear, and know I am treated with competence, dignity, and privacy, I exercise my option to obtain an audio only or an audio-videotape of my personal procedure in its entirety. I know there is no cost for the taping when I provide my own tape. I want a recording by the following method: I want . . . [choose one]: ____ an ____ an edited audio and videotape (before and after only) of my findings before treatment and my results after treatment without recording the actual treatment procedure itself. ____ an audiotape only (no videotape). ____ no tape (no audio or video) because my Practitioner and/or I are uncomfortable being either audio or videotaped. I [choose one]: ____ I want sole ownership of my tape - no copies. ____ I agree to permit copies of my tape for education purposes.
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Last modified: June 20, 2008 |
