I, as __________________ of _____________ hereby authorize ____________________ and associates and assistants as designated by ____________________ to perform the following medical procedure:
________________________________________________________________
It has been explained to me that during the course of the operation or procedure, unforeseen conditions may be revealed or encountered in ___________________ that necessitate surgical or other procedures in addition to or different from those contemplated, I further require and authorize _______________________, associates and assistants, to perform additional procedures as they may deem immediately necessary.
I consent to administration of anesthesia and to the use of such anesthetic as may be deemed necessary.
I further consent to the administration of such drugs, infusions, plasma or bloods transfusion deemed necessary in the judgment of ____________________, and associates and assistants as designated by ____________________.
I further consent to the examination for anatomical purposes and disposal by the hospital of any bodily tissues and parts that may be removed during the procedure….
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