I, ______________________________________, hereby consent to the performance of
by my urologist, Dr. __________________________.
I have been made aware of the nature of my medical condition, alternatives to the proposed surgery, as well as the risks, benefits and complications. In addition, I acknowledge that I have been given ample opportunity to ask questions concerning the surgery and that these have been answered to my satisfaction.
I furthermore understand that all circumstances that might arise during and/or after the proposed surgery cannot be foreseen, and instruct the above named physician to deal with such circumstances as sound medical judgement would dictate.
Date: _________________ Patient or (Guardian): _________________________________
Date: _________________ Physician: ______________________________