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Surgery Consent form below Minimize File Preview Review one of them and identify the five requirements within that consent form; explain where and how each element is noted within the actual form itself. Then, analyze the purpose for such consent forms from both the patient’s and organization’s viewpoints. Your paper should be two to three pages in length, excluding the title and reference pages; include at least two scholarly sources, in addition to the text; and be written in APA format. I have had the opportunity to have my questions answered to my satisfaction. □ “Language Line” SM used for interpretation. I authorize my physicians and Martin Memorial to disclose health informati on related to this treatment or procedure to any friend or family member who has accompanied me or who is waiting for me, even if I am competent or available, with the exception of the following: _______________________________________________ _______________________ ________________________________________ ________________________________ Patient/Authorized Surrogate Or Proxy Signature Date/Time ________________________________________ __________________________ Witness Signature Date/Time I certify that I have explained the nature, purpose, benefits, risks, complications, and alternatives of the proposed procedure to the patient or the patient’s legal representative. I have answered all questions fully, and I believe that the patient/legal representative fully understands what I have explained. I further certify that I have validated the procedure/site and side, and that the correct procedure site has been marked, if indicated, prior to the procedure being performed. __________________________________________ __________________________ Practitioner Signature Date/Time MARTIN MEMORIAL HEALTH SYSTEMS STUART, FL SURGERY CONSENT RM056 Rev 11/00 2/01, 6/03, 10/05, 2/06, 3/07, 5/07, 4/08, 01/09; 7/11; 1/12; 5/12 G/Consent Forms/surgical consent 056 REVISIONS MADE TO THIS CONSENT MUST BE APPROVED BY RISK MANAGEMENT.