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): _________________________________

I have explained in detail the nature of the medical condition, proposed surgery, its alternatives, risks and benefits. I have expressly explained that no guarantee or warranty can be given regarding the surgical outcome. I find the patient competent to understand the above and thereby provide informed consent.

Date: _________________ Physician: ______________________________