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Facility Consent For Surgery - Surgery Center of the Lakelands 2026
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- Click ‘Get Form’ to open it in the editor.
- 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.
- Fill in the MR # (Medical Record Number) to ensure accurate record-keeping.
- In the 'Procedure(s)' section, clearly list all procedures that are being authorized. Be specific to avoid any confusion.
- Indicate the planned surgical side by checking either RIGHT, LEFT, or BILATERAL as applicable.
- Review the consent statements carefully. Ensure you understand each point before proceeding to sign.
- 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.
- If applicable, have an interpreter or reader sign and print their name along with the date.
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