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U N I V ER SIT Y OF V I RGI N I A HE A LT H SYST E M0100000PLACE LABEL HERE.IF LABEL NOT AVAILABLE, WRITE IN PT NAME & MR#CONSENT FOR PYELOPLASTY AND ADMINISTRATION OF ANESTHESIA OR SEDATION A. CONSENT
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How to fill out consent for pyeloplasty and

01
Obtain the consent form from the healthcare provider.
02
Read the entire consent form carefully.
03
Fill in your personal information at the top of the form, including your name and date of birth.
04
Review the details regarding the pyeloplasty procedure, including risks, benefits, and alternatives.
05
Ask questions if any part of the form or procedure is unclear to you.
06
Initial each section of the form as required, indicating your understanding of each point.
07
Sign and date the bottom of the consent form to indicate your consent for the procedure.

Who needs consent for pyeloplasty and?

01
Patients undergoing pyeloplasty.
02
Legal guardians or parents of minors undergoing the procedure.
03
Patients unable to provide informed consent due to medical conditions.
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Consent for pyeloplasty is a legal document that a patient signs to give permission for the surgical procedure, indicating that they understand the risks, benefits, and alternatives associated with the surgery.
The surgeon or the healthcare provider performing the pyeloplasty is responsible for ensuring that the consent form is filled out and signed by the patient or their legal guardian before the procedure.
To fill out the consent for pyeloplasty, the healthcare provider must provide information about the procedure, discuss the risks and benefits with the patient, and then have the patient (or guardian) sign the form, affirming their understanding and agreement.
The purpose of consent for pyeloplasty is to ensure that the patient is informed about the surgery and agrees to proceed, thereby protecting both the patient’s rights and the medical provider's legal interests.
The consent form for pyeloplasty must include information such as the patient’s name, the procedure being performed, explanations of the risks and benefits, alternatives to the procedure, and the signatures of the patient and healthcare provider.
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