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(Affix patient identification label here) Beneficence and Nonmaleficence
Neurosurgeon and Spine Surgeon
Carpal Tunnel Release
A. Interpreter / cultural needs
• Redness and peeling of the palm. This usually Uncommon risks and complications include:
If yes, is a qualified Interpreter present? • Bleeding can occur and may require a return to the operating room. Bleeding is more common if you have been taking blood thinning drugs such If yes, is a Cultural Support Person present? Yes No as Warfarin, Asprin, Clopidogrel (Plavix or B. Condition and treatment
The doctor has explained that you have the following • Numbness and tingling in the fingers and thumb condition: (Doctor to document in patient’s own • The operation occasionally does not work and • Damage to the tendons, which may require • Damage to the median nerve, requiring re- This condition requires the following procedure. (Doctor to document - include site and/or side where • Wrist pain when making a fist or leaning on the • The surgical cut may cause changes to the • In some people, healing of the wound can become thickened and red and the scar may be Rare risks and complications include:
• Increased risk in obese people of wound infection, chest infection, heart and lung • Severe burning pain, unresponsive to treatment. co
• Death as a result of this procedure is very rare. D. Significant risks and procedure
(Doctor to document in space provided. Continue in A Carpal Tunnel release is a procedure to free the median nerve which runs through the carpal tunnel in E. Risks of not having this procedure
(Doctor to document in space provided. Continue in
C. Risks of this procedure
There are risks and complications with this procedure. They include but are not limited to the following. Common risks and complications include:
• Infection, requiring antibiotics and further • Minor pain, bruising and/or infection from IV cannula site. This may require treatment with (Affix patient identification label here) Beneficence and Nonmaleficence
Neurosurgeon and Spine Surgeon
Carpal Tunnel Release
F. Anaesthetic
This procedure may require an anaesthetic. (Doctor I request to have the procedure
to document type of anaesthetic discussed) Name of Patient/
Substitute decision
maker and relationship:.
Signature:.
Date:.…………………………………………………… …….
Substitute Decision-Maker: Under the Powers of Attorney Act
G. Patient consent
1998 and/or the Guardianship and Administration Act 2000. If the patient is an adult and unable to give consent, an authorised I acknowledge that the doctor has explained; decision-maker must give consent on the patient’s behalf. • my medical condition and the proposed procedure, including additional treatment if the H. Doctor’s statement
doctor finds something unexpected. I understand the risks, including the risks that are specific to I have explained to the patient all the above points under the Patient Consent section (G) and I am of the opinion that the patient/substitute decision- • the anaesthetic required for this procedure. I understand the risks, including the risks that are Doctor:.
• other relevant procedure options and their Designation:.
• my prognosis and the risks of not having the Signature:.
• that no guarantee has been made that the .…………………………………………………………….
procedure will improve my condition even though Anaesthetist:
it has been carried out with due professional Designation:.
• the procedure may include a blood transfusion. Signature:.
• tissues and blood may be removed and could be Date:.…………………………………………………………….
condition, stored and disposed of sensitively by I. Interpreter’s statement
• if immediate life-threatening events happen during the procedure, they will be treated • a doctor other than the Specialist Neurosurgeon (state the patient’s language here) of the consent may conduct the procedure. I understand this form and assisted in the provision of any verbal and could be a doctor undergoing further training. written information given to the patient/parent or I have been given the following Patient
guardian/substitute decision-maker by the doctor. Information Sheet/s;
Interpreter:
Local Anaesthetic for Your Procedure
Carpal Tunnel Release
Signature: .
• I was able to ask questions and raise concerns Date:.…………………………………………………………….
with the doctor about my condition, the proposed procedure and its risks, and my treatment options. My questions and concerns have been discussed and answered to my satisfaction. • I understand I have the right to change my mind at any time before the procedure, including after I have signed this form but, preferably following a Consent Information - Patient Copy
Carpal Tunnel Release
Beneficence and Nonmaleficence
Neurosurgeon and Spine Surgeon
1. What is a Carpal Tunnel Release?
• Damage to the tendons, which may require A Carpal Tunnel release is a procedure to free the median nerve which runs through the carpal tunnel in • Damage to the median nerve, requiring re- It involves making a small cut down the front of the • Wrist pain when making a fist or leaning on the wrist and palm of the hand and dividing the band of tissue which is pressing on the median nerve. • The surgical cut may cause changes to the Once the nerve is completely free, the skin is closed • In some people, healing of the wound can become thickened and red and the scar may be Rare risks and complications include:
• Increased risk in obese people of wound infection, chest infection, heart and lung complications and • Severe burning pain, unresponsive to treatment. • Death as a result of this procedure is very rare.
Notes to talk to my doctor about
Medical illustration Copyright Nucleus Medical Art. Al Rights Reserved.
2. My anaesthetic
This procedure will require a Local Anaesthetic. See Local Anaesthetic for Your Procedure patient
information sheet for information about the anaesthetic and the risks involved. If you have any concerns, talk these over with your doctor. If you have not been given an information sheet, 3. What are the risks of this specific
procedure?
There are risks and complications with this procedure. They include but are not limited to the following. Common risks and complications include:
• Infection, requiring antibiotics and further • Minor pain, bruising and/or infection from IV cannula site. This may require treatment with • Redness and peeling of the palm. This usually Uncommon risks and complications include:
• Bleeding can occur and may require a return to the operating room. Bleeding is more common if you have been taking blood thinning drugs such as Warfarin, Asprin, Clopidogrel (Plavix or Iscover) or Dipyridamole (Persantin or Asasantin). • Numbness and tingling in the fingers and the • The operation occasionally does not work and

Source: http://drpope.com.au/Patient%20Handouts/Consent_Forms/Consent_Carpal_Tunnel_Decompression.pdf

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PLEASE COMPLETE THE FOLLOWING CONFIDENTIAL INFORMATION PATIENT REGISTRATION IF YOUR CHILD S LAST NAME AND/OR ADDRESS ARE NOT THE SAME AS YOURS, FILL IN THE TOP BOX ALSOPERSON FINANCIALLY RESPONSIBLE FOR ACCOUNTRELATIONSHIP TO PATIENT SOCIAL SECURITY NO. IS ANOTHER MEMBER OF YOUR FAMILY OR RELATIVE A PATIENT AT OUR OFFICE? YOU WERE REFERRED TO US BY YOUR FORMER ADDRESS PERSON TO

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Milk Thistle Text by Armando González Stuart, Ph.D., 2005 Botanical family: Asteraceae (Compositae). Other common names: Marian thistle, St. Mary’s Thistle. Common names in Spanish: Cardo mariano, Cardo lechoso. Medicinal parts: The dried, ripe fruits or achenes (“seeds”). The ripe fruits or achenes (“seeds”) of this plant have been employed in Europe for many

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