Authorization for Medical Treatment, Anesthesia, and Performance of Operation

I, as __________________ of ___________________, hereby authorize ____________________ and such associates or assistants as may be designated by ____________________, to perform the following medical procedure:

________________________________________________________________

It has been fully explained to me that during the performance of the above procedure, unforeseen conditions may arise or be discovered in ___________________. In such cases, I authorize ____________________ and their designated associates or assistants to perform any additional or alternative procedures that they deem medically necessary and appropriate at that time.

I consent to the administration of anesthesia and authorize the use of any anesthetic agents deemed necessary by the attending medical professionals.

I further consent to the administration of any medications, intravenous fluids, plasma, or blood transfusions that, in the professional judgment of ____________________ and their designated associates or assistants, are considered necessary.

I also authorize the hospital to examine and dispose of any bodily tissues or parts removed during the procedure for anatomical or medical purposes, as deemed appropriate.

I additionally consent to the photographing, videotaping, or closed-circuit televising of the procedure, as well as the publication of such recordings, provided my identity is not disclosed. I understand that these recordings may be used strictly for medical, scientific, or educational purposes. I hereby waive any rights or claims to compensation in connection with the exhibition or use of such recordings.

The nature, purpose, and necessity of the proposed procedure, including alternative treatment methods, potential risks, and possible complications, have been fully explained to me. I understand this information. I acknowledge that the practice of medicine and surgery is not an exact science and that no guarantees or assurances have been made regarding the results of the procedure.

This consent is being given by ___________________ due to the inability of ___________________ to provide consent because:

_____________________________________________________________

Dated: ___________________

Time of Signature: ___________

______________________________________ ___________________

Signature of Authorizing Party

_______________________

Witness: ____________________________________

Authorization for Medical Treatment, Anesthesia, and Performance of Operation

How to Use This Sample Format

This guide is provided to help you understand and properly prepare this medical authorization document. Having this form signed and on file is crucial, especially in cases where urgent medical treatment may be required. It is a proactive and responsible measure for your overall healthcare planning.

Make multiple copies of the completed form. Provide one to your primary care physician and any specialists who may be involved in your care, so that it is readily available if needed. It is also advisable that your spouse or legal representative has a copy for immediate access.