(full name), in my capacity as:

• Patient over 18 years of age

• Parent/Guardian of patient:

(full name), who is my: Spouse/ Partner/ Child/ Grandchild/ Parent/ Sibling/ Foster child/ Ward (please circle the applicable)

do hereby give my consent for the performance of the procedure:

by Dr

at Lakefield Surgical Centre on (date)

I also give consent for the administration of pre-medication and an anaesthetic in the form of general and / or local anaesthetic (at the anaesthetists discretion) as well as the insertion of a suppository for pain control and to such other additional surgical procedures as the surgeon deems necessary and has been authorised to do.

I am satisfied that the surgical procedures as well as the anaesthetic procedure have been fully explained to me, that the concerns have been adressed and that my questions have been answered to my satisfaction, leaving me in a satisfactory position to weigh up the risks and understand the limitations of the procedure. Significant potential complications of both the surgery and the anaesthetic have been explained to me and I have had the opportunity to discuss alternative treatment modalties. (Complications include but are not limited to: Bleeding, infections, hermatoma, need for subsequent surgery, scar formation, local tissue infarction and necrosis, post-operative pain, prolonged pain, intractable pain, failed procedure, varied results, psychological alterations, embolism, depression, nerve damage, permanent numbness, slow healing)

1. In the event that the surgeon or the anaesthetist deem that a transfusion of blood or blood products is necessary during the procedure, I certify that I am over 14 years of age and that (mark only one)

• I accept the decision made by the surgeon/anaesthetist and authorize such transfusion

• I object to such transfusion despite the surgeons warnings and indemnify the Clinic against any adverse medical consequences of my decision, including possible disability or even death.

1. I hereby authorise and require the Clinic to destroy such tissues as are removed from me during the procedures.

2. I acknowledge that I have had the opportunity to discuss the costs of the hospitalization as well as possible additional expenses which may arise should complications occur. I further acknowledge that I remain responsible for the payment of all hospital expenses irrespective of any contract that may exist between myself and any third party such as my medical aid.

3. I understand that no guarantee can be issued for and uneventful course of the procedure or of the subsequent recovery period, but that the surgeon, the anaesthetic and the nursing staff will take all necessary steps to reduce the likelihood of those complications occurring.

4. I consent to the release of clinical information, including HIV status, to professional members of the medical and nursing team responsible for the patient's treatment and care.

5. I understand that in the event of litigation arising consequent to the surgery, or can only be done in South Africa under South African law and that "Lakefield Surgical Centre", its management or staff cannot be held liable in any way whatsoever.