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Consent of a patient invasive and (or) interventional procedure

APPROVED
by the Order No. V- of    February 2020
of Director
of Šiauliai National Hospital, Public Institution

CONSENT OF A PATIENT AT ŠIAULIAI NATIONAL HOSPITAL, PUBLIC INSTITUTION, REGARDING THE SURGERY, INVASIVE, AND (OR) INTERVENTIONAL PROCEDURE

1. Name, company No., address, telephone of personal health care institution where the patient shall undergo the surgery, invasive, and (or) interventional procedure.
       National Hospital, Public Institution, company No. 245386220, V. Kudirkos St. 99, LT-76231 Šiauliai, tel. (8 41) 524 257. 

2.  Name, telephone of the division (unit, etc.) where the surgery, invasive, and (or) interventional procedure shall take place.
__________________________________________________________________________________

3. Name, professional qualification of a physician performing the surgery, invasive, and (or) interventional procedure.
________________________________________________________________________________

4. Name or ID number, when the identity is not disclosed, age of the patient undergoing the surgery, invasive, and (or) interventional procedure.
________________________________________________________________________________

5. The nature of the surgery, invasive, and (or) interventional procedure (summary).

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
     
6. Consideration regarding the admissibility to change the extent of the surgery, invasive, and (or) interventional procedure(s) if there is no possibility to discuss it with the patient during it (them), and it is impossible to anticipate it when giving the consent. 
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

7. The nature, aims, risks of alternative diagnostics and treatment methods of the surgery, invasive, and (or) interventional procedure(s), and other circumstances important to the patient.
______________________________________________________________________________________________________________________________________________________________________

8. Possible complications that are important for the resolve of the patient to give their consent for the scheduled surgery, invasive, and (or) interventional procedure:
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________

9. Other circumstances important for the resolve of the patient:
     _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
     
10. Application/non-application of anaesthesia during the surgery, invasive, and (or) interventional procedure:
     If the procedure is performed under the supervision of Anaesthesiologist – Reanimatologist, then Anaesthesiologist-Reanimatologist familiarises the patient with the type and course of anaesthesia by a separate information and consent form. 

11. Patient’s confirmation:
     By signing the present document, I hereby confirm that the Physician have provided me with comprehensible explanations about my illness, illness treating methods, the nature, point, aims of the scheduled surgery, invasive, and (or) interventional procedure, the known and possible alternative diagnostics and treatment methods of the procedure, their aims, peculiarities, risks, and other important circumstances which could have had an impact on my decision to give my consent to or to refuse to have the surgery, invasive, and or interventional procedure performed, also possible consequences if the surgery, invasive, and or interventional procedure is not performed. 
     By signing the present document, I hereby agree and request to have the aforementioned surgery(s) (procedure(s)) performed by the physicians of this Hospital. I am aware that the Physician may invite other physicians to assist them, participate in the surgery (procedure), or carry out a part thereof.  
     I have received comprehensible explanations that I may bleed out, or require the transfusion of blood or blood substitutes during the surgery, invasive, and (or) interventional procedure. I have been familiarized with the risk. I agree to have the transfusion of blood or its products should the Physician decide this to be necessary. 
I am aware that I shall receive qualified help in case of complications. 
     I am aware that the medical science is not perfect (accurate), and it is difficult to anticipate many aspects. 
     I am aware that I may have to receive treatment at the Hospital for longer than anticipated, while the recovery and incapacity for work might also take longer than anticipated. 
     I am aware that I must inform my physicians of all past health disturbances, illnesses, surgeries, medications taken in the past and at the moment, narcotic substances, allergic reactions, genetic heredity, and other details available to me that are necessary for proper provision of health care services. 
      I have been informed about my obligation to cooperate with the Physician, follow their orders, and prescriptions, notify them about any deviations from the prescriptions. 
      I have read (or have had it read to me) the text of the consent to the surgery, invasive, and (or) interventional procedure, and have understood the oral explanations of the Physician and the present text, and thus give my consent to have the surgery, invasive, and (or) interventional procedure performed. 

Name of the patient (their representative), basis of representation______________________________
___________________________________________________________________________________

Signature of the patient (their representative)_____________ Date:___________ Time: ____________

12. Physician’s confirmation:
     I hereby confirm that I have extensively discussed with the patient (their representative) and assessed the benefits and risks of the surgery, invasive, and (or) interventional procedure, and have provided sufficient information to the patient (their representative) for them to make a resolve about the suggested surgery, invasive, and (or) interventional procedure. 

Physician’s name, signature______________________________________________________

Familiarisation date: _____________  Time: ___________________
 

Last updated: 18-03-2020