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:
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:
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]
Statement Templates @ Template.net
