Get Laparoscopic Appendectomy Consent Form

What is an informed consent form? The medical staff will carefully explain the surgery to you before you have it. This includes why you are having it, any risks the surgery has, and what you can expect afterward. You will also be asked to sign an informed consent form.

A surgical consent form is used to ensure a patient has been provided with all the necessary information concerning a proposed surgery/special procedure and to document that they agree to undergo the operation. Any risks associated with the procedure and treatment thereafter must be outlined in the form.

A laparoscopic (lap-a-ro- SKOPP-ik) or “lap” appendectomy is a minimally invasive surgery to remove the appendix through several small incisions, rather than through one large one. Recovery time from the lap appendectomy is short.

My physician(s) has fully explained to me the condition requiring treatment and the nature, purpose, risk and benefits of the operation(s) / procedure(s), possible alternative methods of treatment, including non-treatment, and the possibility of complications.

7 days prior to surgery: Stop taking vitamins, herbal remedies, and other dietary supplements. 3 days prior to surgery: Stop taking NSAIDs such as ibuprofen (Advil, Motrin) and naproxen (Aleve). Anesthesia will discuss all other medications when they call the day before your surgery.

I request and authorize my physician and other qualified medical personnel to perform such treatment or procedures as required. I have chosen to undergo this procedure after considering the alternative forms of diagnosis and/or treatment for my condition including no treatment or other procedures or tests.

I understand that my participation is voluntary and that I am free to withdraw at any time, without giving a reason and without cost. I understand that I will be given a copy of this consent form. I voluntarily agree to take part in this study.