手术知情同意书模板.docx

__________________________________________________________________________________________________________________________手术知情同意书尊敬的患者:您好!根据您目前的病情,您有此手术适应症,医师特向您详细介绍和说明如下内容:术前诊断、手术名称、手术目的、术中拟使用高值医用耗材和仪器、术中或术后可能出现的并发症、手术风险及替代医疗方案等。帮助您了解相关知识,作出选择。一般项目医师告知患者姓名________           性别_________         年龄___________科  室 ________           病房_________         病案号_________【术前诊断】_______________________________________________________________________________。【拟手术指征】(手术禁忌症)_______________________________________________________________________________。【替代医疗方案】(不同的治疗方案及手术方式介绍)根据您的病情,目前我院主要有如下治疗方法和手术方式:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________。【建议拟行手术名称】【手术目的】【手术部位】【拟行手术日期】___________________________________________________________  。【拒绝手术可能发生的后果】                                                   。【患者自身存在高危因素】______________________________________________________________________________________________________________________________________。【术中拟使用高值医用耗材和仪器】□自费 □部分自费 □医保 □新型农村合作医疗 □超过千元___________________________________________________________