Administrative — Generic Procedure Informed Consent

CONSENT FOR MEDICAL / SURGICAL PROCEDURE Patient Name: [Patient Name] DOB: [Date of Birth] 1. Procedure:

I authorize Dr. [Provider Name] and assistants to perform the following procedure:

[Name of Procedure, e.g., Skin Biopsy / Joint Injection / I&D] Location/Site: [e.g., Left Knee, Upper Back] 2. Explanation:

The nature and purpose of this procedure have been explained to me. I understand it is being done to: [e.g., Diagnose a lesion / Relieve pain / Drain infection].

3. Risks:

I understand that all procedures carry risks. Common risks include, but are not limited to:
* Pain / Discomfort
* Bleeding / Bruising
* Infection
* Scarring
* Allergic reaction to anesthetic
* Nerve damage (numbness/weakness)
* Recurrence of condition
* Need for further treatment

4. Alternatives:

The alternatives to this procedure have been explained, including:
* Doing nothing (observation)
* Medical management (medication)
* Referral to a specialist

5. Questions:

I have had the opportunity to ask questions about the procedure, risks, and alternatives. My questions have been answered to my satisfaction.

Consent:

Knowing these risks, I voluntarily consent to this procedure.

Signature: __________________________ Date: [Date]

[Patient Name]

Provider Certification:

I have explained the procedure, risks, benefits, and alternatives to the patient/guardian.

Provider: __________________________ Date: [Date]