Rosa Lemus

1. I hereby authorize the physician listed below and whomever he/she may designate as his/her assistants to administer such treatment as may be necessary and to perform upon the following procedure:

Diagnostic/Operative Laparoscopy

Performing Physician: David H. Weir, M.D.

If any unforeseen condition arises in the course of the operation, calling in his/her judgment for procedures in addition to or different from those now contemplated, I further request and authorize him/her to do whatever he/she deems necessary.

2. My doctor has explained the nature and purpose of the operation and risks involved have been explained fully to me and no guarantee or assurance has been made as to the results that may be obtained.

3. I consent to the administration of such anesthetics as may be considered necessary or advisable by the physician listed responsible for this service.

4. I hereby authorize the hospital pathologist or personnel to use their discretion in disposal of any material removed from my body.

5. I understand that the procedure may require the use of video equipment and/or may be video taped for clinical, educational or research purposes.

6. I consent to the presence of observers including sales representatives during my procedure at my doctor’s discretion.

7. I understand the administration of blood and/or blood products may be necessary advisable by my physician(s) during my procedure or post procedure hospitalization

[ ] I consent to administration of blood and/or blood products

[ ] I refuse the administration of blood and/or blood products

I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE AUTHORIZATION AND THAT ALL BLANKS OR STATEMENTS REQUIRING INSERTION OR COMPLETION WERE FILLED BEFORE I SIGNED.

Witness Signature of Patient

Date Time A.M.,P.M.

Place (Room, Office, etc)

IF PATIENT IS A MINOR OR IS PHYSICALLY OR MENTALLY INCOMPETENT

Reason Incompetent-minor, etc Signature of Person Authorized to Sign

Witness to signature Relationship to Patient

Witness Place (Room, Office, Telephone, etc)

Date A.M./P.M.

[ ] Risk, benefits and alternatives documented by physician in record

[ ] I have explained the operation/procedure, alternatives, benefits and risks to the

patient and have answered the patient’s questions. To the best of my knowledge,

I feel the patient has been adequately informed and has consented.

_____________________________

Physician signature Date/Time

AUTHORIZATION FOR MEDICAL AND/OR SURGICAL

TREATMENT AND/OR AUDIO-VISUAL AUTHORIZATION