Optional Form 522 PDF Details

Before undergoing certain medical procedures, it's crucial for patients to understand what they are consenting to, which is encapsulated in the Optional Form 522. This form, a key document required by healthcare institutions, is designed to ensure that patients are fully informed about the specifics of their upcoming medical treatments, including surgeries and the administration of anesthesia. From detailing the type of procedure, explaining the associated risks and alternatives, to outlining the role of anesthesia, the form serves as a comprehensive request and consent document. It encompasses a wide range of procedures such as operations, sedations, transfusions, and others that might necessitate the removal of tissues or parts, emphasizing the patient's understanding and consent to these elements. Moreover, the form covers the consent to take photographs or movies for medical or dental study or research, with strict anonymity provisions. It also provides provisions for when a health care industry representative might be present during the procedure. Signatures from the patient, counseling physician or dentist, and, if applicable, a sponsor or legal guardian, finalize the consent, ensuring that all parties have discussed and agreed upon the nature, risks, and expectations of the procedure. This critical form fosters a communicative environment between patients and medical professionals, safeguarding informed consent and autonomy within the medical process.

QuestionAnswer
Form NameOptional Form 522
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesGSA, signif, forms 522, form

Form Preview Example

REQUEST FOR ADMINISTRATION OF ANESTHESIA AND FOR PERFORMANCE OF OPERATIONS AND
OTHER PROCEDURES
MEDICAL RECORD
OPTIONAL FORM 522 (REV. 7/2008) Prescribed by GSA/ICMR FMR (41 CFR) 102-194.30(i)
DoD Exception to OF 522 approved by GSA

AUTHORIZED FOR LOCAL REPRODUCTION

MEDICAL RECORD

REQUEST FOR ADMINISTRATION OF ANESTHESIA

AND FOR PERFORMANCE OF OPERATIONS AND OTHER PROCEDURES

A. IDENTIFICATION

1a. (Check all applicable boxes)

 

OPERATION OR PROCEDURE

 

SEDATION

 

 

 

 

 

ANESTHESIA

 

TRANSFUSION

 

 

 

 

1b. DESCRIBE

B. STATEMENT OF REQUEST

2.The nature and purpose of the operation or procedure, possible alternative methods of treatment, the risks involved, and the possibility of complications have been fully explained to me. I acknowledge that no guarantees have been made to me concerning the results of the operation or procedure. I understand the nature of the operation or procedure to be (describe operation or procedure in layman's language)

which is to be performed by or under the direction of Dr.

3.I request the performance of the above-named operation or procedure and of such additional operations or procedures as are found to be necessary or desirable, in the judgment of the professional staff of the below-named medical facility, during the course of the above-named operation or procedure.

4.I request the administration of such anesthesia as may be considered necessary or advisable in the judgment of the professional staff of the below-named medical facility.

5.Exceptions to surgery or anesthesia, if any are:

(If "none", so state)

6.I request the disposal by authorities of the below-named medical facility of any tissues or parts which it may be necessary to remove.

7.I understand that photographs and movies may be taken of this operation, and that they may be viewed by various personnel undergoing training or indoctrination at this or other facilities. I consent to the taking of such pictures and observation of the operation by authorized personnel, subject to the following conditions:

a.The name of the patient and his/her family is not used to identify said pictures.

b.Said pictures be used only for purposes for medical/dental study or research.

8.I understand that as indicated a Health Care Industry Representative or other authorized personnel may be present.

(Cross out any parts above which are not appropriate)

C. SIGNATURES

(Appropriate items in parts A and B must be completed before signing)

9.COUNSELING PHYSICIAN/DENTIST: I have counseled this patient as to the nature of the proposed procedure(s), attendant risks involved, and expected results, as described above. I have also discussed potential problems related to recuperation, possible results of non-treatment, and signif icant alternative therapies.

(Signature of Counseling Physician/Dentist)

10.PATIENT: I understand the nature of the proposed procedure(s), attendant risks involved, and expected results, as described above, and hereby request such procedure(s) be performed.

(Signature of Witness, excluding members of operating team)

 

(Signature of Patient)

 

(Date and Time)

11. SPONSOR OR GUARDIAN: (When patient is a minor or unable to give consent)

sponsor/guardian of

 

understand the nature of the proposed procedure(s), attendant risks involved, and

 

 

 

expected results, as described above, and hereby request such procedure(s) be performed.

(Signature of Witness, excluding members of operating team)

 

(Signature of Sponsor/Legal Guardian)

 

(Date and Time)

PATIENT'S IDENTIFICATION

(For typed or written entries, give: Name -- last, first, middle; ID no.( SSN or other); hospital

or medical facility)

 

REGISTER NO.

WARD NO.

How to Edit Optional Form 522 Online for Free

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Step 2: The editor lets you customize most PDF documents in a variety of ways. Change it with any text, correct existing content, and put in a signature - all doable within minutes!

With regards to the blank fields of this specific form, here is what you should do:

1. Begin completing your forms 522 with a selection of essential blank fields. Collect all of the required information and ensure not a single thing missed!

Stage no. 1 in completing form

2. Soon after finishing this section, head on to the next step and complete the necessary details in these blanks - PATIENT I understand the nature, Signature of Witness excluding, Signature of Patient, Date and Time, SPONSOR OR GUARDIAN When patient, sponsorguardian of, understand the nature of the, expected results as described, Signature of Witness excluding, Signature of SponsorLegal Guardian, PATIENTS IDENTIFICATION, For typed or written entries give, REGISTER NO, Date and Time, and WARD NO.

Writing part 2 in form

Be really attentive when completing REGISTER NO and understand the nature of the, because this is the part where most people make errors.

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