Patient Consent Example

Patient Consent Form

Example of Patient Consent Form

Patient Consent Template Example


I, the undersigned: _______________________________________________________________


Give consent to the following :


Operation/procedure/treatment/process, upon myself/my spouse/ my dependent 

----------------------------------------------- By Dr Thane W Munting

  1. My surgeon has provided me with a general explanation of the nature of this operation/procedure/treatment/process and the reasons for its indication based on my particular medical condition.
  2. My surgeon has also discussed with me the risks and benefits of the operation/procedure/treatment/process.  Some of these risks include, but are not limited to, the following:

General surgical complications: infection, allergic reactions, wound breakdown, nerve and blood vessel injury, haematoma, DVT, Pulmonary embolism, blood loss requiring transfusion, prolonged hospitalization, loss of limb, death.

3. My surgeon has also explained that I can generally expect the following possible consequences and complications as a natural result of the risk of undergoing intervention (some of which are attendant to an invasive procedure). Although some of these may not occur, including but not limited to, the following:

Specific complications: failure of relief of symptoms, dislocation/instability, fracture, heterotrophic bone formation, stiffness due to scarring, traction neuropraxia, implant failure, instrumentation failure and implant malposition, limb length inequality, non-union, Avascular Necrosis, non-resolution or recurrence of symptoms.

4. My surgeon has explained alternatives to undergoing this operation/treatment/procedure/process including alternative operative measures that may be deemed necessary or desirable during the course of this operation/procedure/treatment/process, also inclusive of:

Reoperation due to unforeseen complications arising from surgery.

5. I furthermore grant consent to the administration of a general or other anaesthetic for the purposes of the said operation/procedure/treatment/process or alternative operative procedures.  I moreover hereby grant consent to any radiological or diagnostic examination/laboratory tests/hospital services that are medically indicated or that the doctors may prescribe.

6. Blood transfusion

I hereby consent to a blood/blood product transfusion to myself/the patient upon the instruction of the said medical practitioner if deemed medically indicated.

7. My surgeon has also explained to me that other physicians and health care providers may participate in my care. I therefore extend this authorization to these other physicians and health care providers. Although unlikely, in the event that my physician is not available to perform the above operation/procedure/treatment/process, I understand that this authorization is extended to them. If possible, however, I will be notified of the substitution for rescheduling if needed.

9. [ ] I agree that any medical/scientific data obtained from my operation/procedure/treatment/process can be used anonymously for the furtherance of medical care by way of study/presentation/publication or review for outcomes assessment by Dr Munting and his practice. I understand that this consent for collection of data for research is voluntary, that care will be unaffected whether consent is given or not. The data will be kept confidential and there will be no benefit to individual participants. Ethical guidelines for the management of medical data are provided by the Human Research Ethics Committee, part of the Faculty for Health Sciences, University of Cape Town, Rm E53-46 Old Main Building ,Groote Schuur Hospital, Observatory,7921,

Tel: 021 4066626, Website:


Patient Signature:_________________________  Parent/Gardian:_______________________


10. I acknowledge that I have been informed of my/ the patient’s health status, the range of diagnostic procedures and treatments generally available to myself / the patient, the benefits, risks, surgical approximate costs and consequences generally associated with each option, my / the patient’s right to refuse health services and the implications, risks and obligations of such refusal.

[this clause is included in compliance with section 6 of Act 61 of 2003]

11.  I understand that the outcome of the surgery/procedure/treatment intervention/process is very dependent upon me/my dependent being compliant with respect to the post-operative instructions given verbally or in writing by Dr Munting, the physiotherapists and/or his staff, and that Dr Munting cannot be held liable if there are complications due to non-compliance.

12. After discussing all of the above, my physician gave me an opportunity to ask questions and seek further information regarding to above items. I believe that I do not require further information at this time, and I am prepared to proceed with the recommended operation/treatment/procedure/process.  I believe that my physician has honored my/ the patient’s right to make my/the patient’s own informed health care decision, give my consent voluntarily and freely, and certify that I can give valid consent. I understand that I can revoke this consent at any time up until the time the operation/treatment/procedure/process is started.

13. I acknowledge that I/the patient have been informed of all the above in a language understood by me/the patient.

14. I acknowledge that I am informed with respect to all aspects of medical risk related to pandemics, most recently COVID-19, and specifically the increased risk of complications associated with having surgery. This is especially relevant should I/the patient have been exposed to and/or am currently infected, whether symptomatic or not.

SIGNED AT:_________________________        THIS ______________ DAY OF APRIL 20_____ 

SIGNATURE OF PATIENT...........................................................................................................

                                                        Signature of patient/parent/spouse/guardian

Curator/mandated person/ grandparent/adult child/

Brother/sister        (Specify capacity of signatory)

(See section 7 of Act 61 of 2003) 


WITNESS 1 …………….………………………………WITNESS 2 …..…………………………………………………