INFORMED CONSENT FOR HEALTH CARE

I FREELY AND VOLUNTARY DECLARE THE FOLLOWING:

1. Based on my inalienable right to choose my doctor, he accepted Dr. Luis Alberto Buendia Saavedra, with professional ID 4917113 and specialist ID 8070731 as my Doctor, who is endorsed by and duly authorized to practice the specialty of orthopedics by the offices of Professions of National Public Education.

2. I understand that my medical care has recently started:

What TREATMENT requires (MEDICAL AND / OR SURGICAL) to be determined:

3. Aware that there may be RISKS during my medical care that, although unlikely, are possible, and can be mild, such as: allergy to a drug, and adverse effects derived from its application as well as clinical affectations during the medical examination. Even severe such as: insufficient or painful immobilization of a limb as well as pressure ulcers or neurovascular alterations, and those not foreseen derived from my specific attention.

4. The BENEFIT that I will obtain with this procedure is to try to improve my state of health.

I also understand that I accept that every medical act involves a series of RISKS described in the assessment note, which may be due to my health, congenital or anatomical alterations that I suffer, my history of diseases, current and previous treatments or the medical or surgical procedure to which I have decided to submit. Aware that adverse events may occur during the procedure that endanger my life or damage to an organ that may lead to disability, the Doctor may modify the procedure technique or perform other procedures in order to preserve my life and limit the damage. . (NOM 004 10.1.4 In urgent cases, the provisions of Article 81 of the Regulations of the General Health Law regarding the provision of medical care services will be followed).

5. The treating physician has explained to me about other diagnostic or therapeutic ALTERNATIVES that exist such as: no clinical or surgical intervention. And he has explained to me the following advantages for which he has chosen this procedure among all. I clearly explain to myself that it is elective or urgent and I have understood the possible risks and complications of this care.

6. I am aware that I may require complementary treatments that increase my medical or hospital visits. with the participation of other services or medical units, with the consequent increase in costs. 

7. I have been informed that this digital statement is in my file, and I can revoke it at any time.

8. By virtue of being clarified all my doubts, I GIVE MY CONSENT so that in my person or represented, I can carry out the procedure or medical attention with the inherent risks and I authorize the Doctor so that according to his criteria, change the procedure trying with This will resolve any situation that arises during the anesthetic-surgical act or according to my physical and / or emotional conditions.

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REFUSAL OF INFORMED CONSENT

I hereby DENY consent for the procedure and what derives from it to be practiced on me or my client, aware that I have been informed of the possible consequences as a result of this refusal and the alert data that are required if presented. health care.

I hereby REVOKE the consent given on the date___________________________ and it is my wish not to continue the diagnostic or therapeutic management, which is indicated by me or my client from this date______________. I have been informed of the risks involved and the alert data that I must monitor to seek medical attention. Releasing the doctor and / or Institution of all responsibility, since I have understood the scope of this revocation.

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NAME AND SIGNATURE OF PATIENT OR REPRESENTATIVE

I will send in PDF format to the email artroscopia81@gmail.com. For the validation of this revocation in my digital file.

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