Facility Consent For Surgery - Surgery Center of the Lakelands 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient's Name and Date of Birth (DOB) at the top of the form. This information is crucial for identifying the patient.
3. Fill in the MR # (Medical Record Number) to ensure accurate record-keeping.
4. In the 'Procedure(s)' section, clearly list all procedures that are being authorized. Be specific to avoid any confusion.
5. Indicate the planned surgical side by checking either RIGHT, LEFT, or BILATERAL as applicable.
6. Review the consent statements carefully. Ensure you understand each point before proceeding to sign.
7. Sign and date where indicated as either the Patient or their representative. If someone else is signing, provide their name and relationship to the patient.
8. If applicable, have an interpreter or reader sign and print their name along with the date.

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