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French to Haitian-Creole English to Haitian-Creole Haitian-Creole to French English to French Haitian-Creole to English
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English to Haitian-Creole: Authorization for and Consent to Surgical or Special Diagnostic or Therapeutic Procedure General field: Medical Detailed field: Medical (general)
Source text - English
Name of Patient: _______________________________________________________________________________
The provider or surgeon doing the operation or special procedure is _______________________________________.
I understand that the following operation and/or special procedures have been recommended and explained to me using words that I understand. The following operation(s) or procedure(s) are planned for me and I voluntarily consent and give permission for the following operation and/or special procedures:
The hospital supports people and space to assist my provider(s) and surgeon(s) in their performance of surgical operations and other special diagnostic and therapeutic procedures. These operations and procedures all may involve risks of complications or injury, such as bleeding, infection, or even death, from both known and unknown causes. Therefore, except in cases of an emergency or rare situations, these operations and procedures will not be done unless I have had a chance to talk about them with my provider or surgeon. I have the right to agree to or refuse any suggested operation or special procedure (based upon the description or explanation received). Upon my permission and consent, such operations or special procedures will be done.
I understand that people, who are not physicians, but are trained and licensed (for example, nurse practitioners and physician assistants) may do important parts of the operation or procedure. They will be only doing things allowed by the hospital and by law. Important parts may include, but not be limited to, opening and closing, cauterizing or removing tissue, implanting devices, and placing invasive lines. I am aware that medical students may participate in my surgical care under the direct supervision of my provider or surgeon.
I understand that during my surgery or procedure, my provider or surgeon may find a condition they did not expect. This condition may need additional or different operations or procedure(s) other than what is listed on this form. If my provider or surgeon thinks it would help me, I give my permission for added operations or procedures. This may require the help of another provider or surgeon. I understand these added operations or procedure would be done to avoid the risks of having a second surgery or procedure.
I am aware that vendors or sales representatives who are familiar with equipment and supplies used for the operation or procedure may be present in the operating or treatment room.
My provider or surgeon has determined that the operations or procedures listed above may be beneficial in the diagnosis or treatment of my condition. I have the right to permit or to refuse any proposed operation or procedure at any time prior to its performance. I acknowledge that no warranty or guarantee has been made as to the result or cure. I understand that the explanations that I have been given may not be exhaustive or all-inclusive and that other more remote risks may be involved. However, the information that I have received is enough for me to give my permission to have the operation or procedure.
I understand that any tissues or parts removed from my body will be kept or removed from this hospital following its normal practices.
If someone accidentally comes into contact with my blood or another body fluid during the operation or procedure, I give permission for the hospital to do blood tests for blood-borne infectious diseases, including, but not limited to hepatitis, Acquired Immune Deficiency Syndrome (“AIDS”), and Human Immunodeficiency Virus (“HIV”). I understand that if I come into contact with another person’s blood or body fluid during my treatment I can ask the source person be tested for such infectious diseases. All parties involved will have access to the results. I understand that I have a right to refuse testing by talking to my healthcare team.
Patient or Legally Authorized Person to Complete the Following:
Consent for Blood or Blood Products
☐ I DO CONSENT TO THE ADMINISTRATION OF BLOOD AND/OR BLOOD PRODUCTS, if my provider or surgeon
decides that I need blood and/or blood products during my operation or procedure. I understand and accept
that there are risks associated with receiving these products. General risks may include allergic reactions,
transmission of diseases, fluid overload, and other conditions affecting my body’s systems.
☐ I DO NOT CONSENT TO THE ADMINISTRATION OF BLOOD AND/OR BLOOD PRODUCTS. Although my
provider or surgeon may decide that I need blood or blood products during the operation or procedure, I DO NOT
GIVE MY PERMISSION to receiving blood or blood products. I understand and accept that there may
be risks associated with NOT receiving these products and could result in the my health getting worse or even
my death.
I acknowledge that my medical condition and the operation or procedure have been explained to me, including why I should have the operation or procedure, the possible alternatives and other treatment options, the risks and benefits of having and/or refusing the operation or procedure and other necessary and important information for me to make an informed choice in deciding whether to do the operation and/or procedure. I have had the opportunity to ask questions about my condition, the operation or procedure, the risks, and the alternatives. I have freely chosen to have the operation or procedure and accept the risks as they have been explained to me. I agree that the provider or Surgeon,, Hospital, or the Personnel have not made any warranties or representations about the likely results or success of the operation or procedure for treatment of my medical condition or otherwise.
___________________________________ ______________________________________
Witness Title Patient/Authorized Representative Signature
___________________________________
Date and Time
Patient is unable to sign because they are an unemancipated minor,_________years of age, or for the following reason:_________________________________________________________________________
Therefore, the above consent is made on their behalf.
_______________________________________________ __________________________________
Witness (Must be 18 years of age or older) Closest Relative or Legal Guardian
____________________________________ ________________________________
Date and Time Relationship
I have personally explained to the patient or their representative the information set forth in the above on
_______________________ _______________________________
Date and Time Signature of Provider
Translation - Haitian-Creole
Non paysan an: _______________________________________________________________________________
Founisè sante a oswa chirijyen k ap fè operasyon an oswa pwosedi espesyal la se ___________________________________.
Mwen konprann key o te rekòmande m ak eksplike m operasyon sa a ak / oswa pwosedi espesyal sa yo nan mo ke mwen konprann. Yo te planifye operasyon sa a (yo) oswa pwosedi a (yo) pou mwen epi mwen volontèman bay konsantman m epi bay pèmisyon pou operasyon sa a ak / oswa pwosedi espesyal sa yo:
OPERASYON AN (YO) / PWOSEDI A (YO):
_____________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________
Lopital la sipòte moun ak espas pou ede founisè swen sante mwen an (yo) ak chirijyen an (yo) nan pèfòmans yo nan operasyon chirijikal ak lòt pwosedi dyagnostik espesyal e pwosedi ki ka trete ou. Tout operasyon ak pwosedi sa yo ka enplike risk konplikasyon oswa aksidan, tankou emoraji, enfeksyon, oswa menm lanmò, ke yo kòz koni oubyen enkoni. Se poutèt sa, eksepte nan yon ka ijan oswa yon sitiyasyon ki ra, yo p ap fè operasyon sa yo ak pwosedi sa yo sof si mwen te gen chans pale sou yo ak founisè swen sante oswa chirijyen mwen an. Mwen gen dwa dakò ak oswa refize nenpòt operasyon oswa pwosedi espesyal ke yo sigjere m (baze sou deskripsyon an oswa eksplikasyon kem resevwa a). Sou pèmisyon mwen ak konsantman mwen, y ap fè operasyon oswa pwosedi espesyal sa yo.
Mwen konprann ke moun, ki pa doktè, men yo resevwa fòmasyon ak lisans (pa egzanp, enfimyè pratisyèn, ak asistan doktè) ka fè kèk pati enpòtan nan operasyon an oswa pwosedi a. Y ap sèlman fè bagay ke lopital la ak lalwa pèmèt yo fè. Pati enpòtan sa yo ka gen ladan yo, men ki pa limite a, ouvèti ak fèmen, koterize (itilize yon enstriman cho pou koupe seyen ou geri yon blesi) oswa retire tisi, enplante aparèy, ak mete liy envazif. Mwen konnen ke etidyan nan syans medikal yo ka patisipe nan swen chirijikal mwen anba sipèvizyon dirèk founisè oswa chirijyen mwen an.
Mwen konprann ke pandan operasyon oswa pwosedi mwen an, founisè swen sante oswa chirijyen mwen an ka jwenn yon kondisyon yo pa t atann. Kondisyon sa a ka bezwen plis oswa diferan operasyon oubyen pwosedi ke sa ki nan mansyone nan fòm sa a. Si founisè swen sante oswa chirijyen mwen an panse li (lòt operasyon oswa pwosedi a) ka ede m, mwen bay pèmisyon mwen pou ajoute operasyon oswa pwosedi. Sa ka egzije èd yon lòt founisè oswa chirijyen. Mwen konprann operasyon oswa pwosedi sa yo ke yo ajoute yo ap fèt pou evite risk pou m fè yon dezyèm operasyon oswa pwosedi.
Mwen konnen ke moun ki founi ekipman yo oswa reprezantan lavant ki abitye avèk ekipman e founiti yo itilize pou operasyon an oswa pwosedi a ka prezan nan sal operasyon oswa tretman an.
Founisè swen sante oswa chirijyen mwen an detèmine ke operasyon oswa pwosedi yo ki mansyon pi wo a ka gen benefis nan dyagnostik oswa tretman kondisyon mwen an. Mwen gen dwa pou pèmèt oswa refize nenpòt ki operasyon oswa pwosedi yo pwopoze m nenpòt ki lè anvan yo fè l. Mwen rekonèt ke pa gen okenn garanti oswa asirans sou rezilta a oswa gerizon. Mwen konprann ke eksplikasyon yo ke yo te bay mwen ka pa konplè oubyen pa gen tout bagay ladan l e ke lòt risk ki te aleka ka vin enplike nan operasyon oubyen pwosedi mwen an. Sepandan, enfòmasyon mwen te resevwa a ase pou m bay pèmisyon m pou m fè operasyon an oswa pwosedi a.
Mwen konprann ke lopital la ap kenbe oswa retire nenpòt tisi oswa pati ke yo retire nan kò mwen daprè pratik nòmal li yo.
Si yon moun vin an kontak ak san mwen oswa yon lòt likid ki sot nan kò m pandan operasyon an oswa pwosedi a pa aksidan, mwen bay pèmisyon pou lopital la fè tès san pou maladi enfektye ki sikile pa san, ki gen ladan, men pa limite a epatit, Sendwòm Defisyans Iminodefisyans Aki ("SIDA"), ak Viris Imen iminodefisyans ("VIH"). Mwen konprann si mwen antre an kontak ak san yon lòt moun oswa likid kò l pandan tretman mwen an mwen ka mande moun sa a pou l fè tès la pou maladi enfektye sa yo. Tout moun ki enplike ap gen aksè a rezilta tès yo. Mwen konprann ke mwen gen dwa refize fè tès la lè m pale ak ekip swen sante m nan.
Pasyan an oswa Moun ki gen Otorizasyon Legal ap Konplete sa yo:
Konsantman pou san oswa pwodwi sangen
☐ MWEN BAY KONSANTMAN M POU ADMINISTRASYON SAN AK/ OSWA PWODWI SANGEN, si founisè swen sante oswa chirijyen mwen an deside ke mwen bezwen san ak / oswa pwodwi sangen pandan operasyon oswa pwosedi mwen an. Mwen konprann ak aksepte ke gen risk ki asosye ak resevwa pwodwi sa yo. Risk jeneral yo ka gen ladan yo reyaksyon alèjik, transmisyon maladi, sichaj likidyèn (akimilasyon likid nan poumon yo ak tisi periferik yo), ak lòt kondisyon ki afekte sistèm kò mwen.
☐ MWEN PA BAY KONSANTMAN M POU ADMINISTRASYON SAN AK / OSWA PWODWI SANGEN. Malgre ke mwen founisè swen sante oswa chirijyen mwen an ka deside ke mwen bezwen pwodwi sangen oswa san pandan operasyon an oswa pwosedi a, MWEN PA BAY PÈMISYON MWEN pou resevwa pwodwi sangen oswa san. Mwen konprann e mwen aksepte ka gen risk ki asosye ak PA resevwa pwodwi sa yo epi sa ka koze sante mwen vin pi mal oswa menm lanmò mwen.
Mwen rekonèt ke kondisyon medikal mwen an ak operasyon an oswa pwosedi yo te eksplike m nan, ki gen ladan poukisa mwen ta dwe fè operasyon an oswa pwosedi a, altènativ ki posib yo ak lòt opsyon pou tretman, risk ak benefis ki genyen nan fè ak / oswa refize operasyon an oswa pwosedi a ak lòt enfòmasyon ki nesesè ak enpòtan pou mwen ka fè yon bon chwa nan deside si wi ou non m ap fè operasyon an ak / oswa pwosedi a. Mwen te gen opòtinite pou poze kesyon sou kondisyon mwen an, operasyon an oswa pwosedi a, risk yo, ak altènativ yo. Mwen te libman chwazi fè operasyon an oswa pwosedi a ak aksepte risk yo jan yo te eksplike m nan. Mwen dakò ke Founisè swen sante a oswa Chirijyen mwen an, Lopital la, oswa Pèsonèl la pa te bay okenn garanti oswa fè okenn deklarasyon sou rezilta pwobab oswa siksè operasyon an oswa pwosedi a pou tretman kondisyon medikal mwen oswa oubyen lòt bagay.
___________________________________
Dat ak Lè
Pasyan an pa kapab siyen paske yo se yon minè ki pa emansipe (ki gen mwens ke 18 lane), ________lane, oswa pou rezon sa a: _________________________________________________________________________
Kidonk, konsantman ki anwo a te fè sou non yo.
_______________________________________________ __________________________________
Temwen (Dwe gen 18 lane oswa pi gran) Manm fanmi ki pi pwòch oswa Gadyen Legal
____________________________________ ________________________________
Dat ak Lè Relasyon
Mwen te pèsonèlman eksplike pasyan an oswa reprezantan yo enfòmasyon ki mansyone pi wo a nan:
_______________________ _______________________________
Dat ak Lè Siyati Founisè Swen Sante a
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Translation education
Master's degree - Indiana State University
Experience
Years of experience: 11. Registered at ProZ.com: Dec 2024.
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