CONSENT FOR SURGERY

1. I hereby authorize Dr. ______________________________ and the staff of Suero Hospital

(Siak palibusak ni Dr. ken dagiti staff ti Suero Hospital
to perform _________________________________ and such additional operations and procedures as are
nga mangaramid (Operation or Procedures) ken am-amin nga operasyon ken “procedures”
considered necessary on the basis of there being a threat to life found during the course of said operation to
(maipanggep ti pagsayaatan wenno saan nga pagdaksan iti biag ti pasyente bayat ti pannaka-operar ni)

_________________________________________________, who is my _____________________________________

Myself or Name of Patient (Nagan ti Pasyente) Relationship (Pannakaibagi)

2. The nature and purpose of the operation, the risk involved, and the possibility of complications have been
(Iti maited nga pagsayaatan ti operasyon ken narisgo mapasamak ken posibilidad nga komplikasyon ket
explained to me in my dialect or in a language which I understand. I acknowledge that guarantee has been made
naipakaammo iti pagsasao ng maawatak. Awatek nga adda garantisado ken nasayaat
as to the results that may be obtained.
nga resulta na.)

_______________________________________ ______________________________________
Signature of Witness over Printed Name Signature of Patient over Printed Name
Or Person giving Free Consent

_____________
Date

This authorization must be signed by the patient or by the next of kin in the case of a minor or where the
patient is physically or mentally incompetent.

Patient is minor of ___________ years.

Patient is unable to sign because _______________________________.

 CONSENT TO ANESTHESIA

1. I hereby authorize Dr. ______________________________ and the staff of Suero Hospital

(Siak palibusak ni Dr. ken dagiti staff ti Suero Hospital
to give _________________________________ anesthesia to enable to surgeon to perform operation to
(spinal, regional, general) pammaturog tapno ti seruhano ti operasyon kenni
_________________________________________________, who is my _____________________________________

Myself or Name of Patient (Nagan ti Pasyente) Relationship (Pannakaibagi)

2. The nature and purpose of the operation, the risk involved, and the possibility of complications have been
(Iti maited nga pagsayaatan ti operasyon ken narisgo mapasamak ken posibilidad nga komplikasyon ket
explained to me in my dialect or in a language which I understand. I acknowledge that guarantee has been made
naipakaammo iti pagsasao ng maawatak. Awatek nga adda garantisado ken nasayaat
as to the results that may be obtained.
nga resulta na.)

_______________________________________ ______________________________________
Signature of Witness over Printed Name Signature of Patient over Printed Name
Or Person giving Free Consent

_____________
Date

This authorization must be signed by the patient or by the next of kin in the case of a minor or where the
patient is physically or mentally incompetent.

Patient is minor of ___________ years.

Patient is unable to sign because ______________________________________________________________