1 minute
One who wants to go through the amputation operation must be eligible to fill the Amputation Consent Form. There are some requirements that are required to be met by the applicant. The applicant must be the patient or the legal guardian of the patient. The patient must have received all the necessary information and related alternatives about the amputation. The patient must be in his mental state to make the decision. The patient must have understood all the pros and cons of the operation.
Patient Full Name
Age
Gender
Emergency Contact number
Are you aware of the risks involved in amputation surgery?
Please read the following information carefully and initial each section to indicate that you understand. I understand that the success of amputation depends on many factors. These include the quality of my overall health, and whether I follow the instructions given to me by my doctor. I understand that even with the best of care, there is no guarantee that the amputation surgery will be successful.
Signature
Date