Advance Statement

I. Introduction

This Advance Statement serves as a directive for healthcare providers involved in the surgery or medical procedures of [Patient Name]. It delineates my preferences and instructions concerning anesthesia, surgical methods, and post-operative care, ensuring that my medical care respects my decisions during times when I might not be able to communicate them directly.

II. Patient Information

Patient Information	Details
Patients Name	[Patient Full Name]
Patient ID	[Patient ID Number]
Date of Birth	[Date Of Birth]
Primary Care Physician	[Doctor's Name]
Contact Information	[Contact Information]

III. Surgical Procedure Details

Description of the planned surgical procedure(s): [Description of Procedure]

Date and Location of Procedure:

Date: [Date of Procedure]
Location: [Hospital or Clinic Name]

IV. Anesthesia Preferences

Type of anesthesia requested (if any specific preference exists): [Preferred Anesthesia Type]. This choice has been discussed and agreed upon with the anesthesiologist: [Anesthesiologist's Name], considering the medical suitability and potential risks.

V. Post-Operative Care Instructions

Key instructions for post-operative care:

Patient Information	Details
Pain Management Plan	[Pain Management Details]
Dietary Restrictions/Preferences	[Dietary Needs]
Physical Therapy Requirements	[Physical Therapy Needs]
Special Medical Equipment Needed	[Medical Equipment]
Follow-up Medical Check-up Date	[Follow-up Date]

VI. Emergency Contacts

In case of an emergency during or following the procedure, listed below are the contacts to be notified:

Primary Emergency Contact: [Emergency Contact Name] - Phone: [Emergency Contact Phone]
Secondary Contact: [Secondary Contact Name] - Phone: [Secondary Contact Phone]

VII. Legal Acknowledgment

This statement is made voluntarily to guide my healthcare providers in following my wishes. All information disclosed herein is accurate to the best of my knowledge. I understand that I can modify this directive at any time, providing that any changes are communicated in a signed and dated written document.

[Patient Name]

[Date]