|
Authorize
|
73 (34.6%) |
I authorize medical evaluation and treatment, and release of information for insurance/medical purposes concerning my illness and treatment. |
|
Consent
|
65 (30.8%) |
I also consent to diagnostic studies, tests, anesthesia, X-ray examinations, and any other treatment or courses of treatment relating to the diagnosis or procedure described herein. |
|
May
|
39 (18.5%) |
If any unforeseen circumstances should arise which … require deviation from the original anesthetic plan, I further authorize that whatever other anesthetics or emergency procedures deemed advisable by them may be administered or performed. |
|
Request
|
25 (11.8%) |
I, request and consent to the start or induction of my labor by my provider: [sic] and other assistants as may be selected by him/her. |
|
Agree
|
23 (10.9%) |
I agree that any excess tissue, fluids, or specimens removed from my body during my outpatient visit or hospital stay … may be used for such educational purposes and research, including research on the genetic materials (DNA). |
|
Perform
|
21 (10.0%) |
I, (Wife) authorize the Strong Fertility and Reproductive Science Center to perform one or more artificial inseminations on me with sperm obtained from an anonymous donor for the purpose of making me pregnant. |
|
Give
|
18 (8.5%) |
I give permission to my responsible practitioner to do whatever may be necessary if there is a complication or unforeseen condition duringmy [sic] procedure. |
|
Named
|
13 (6.2%) |
I give permission to the hospital and the above-named practitioner to photograph and/or visually record or display the procedure(s) for medical, scientific, or educational purposes. |
|
Use
|
12 (5.7%) |
I request and consent to use of anonymous donor sperm in hopes of achieving a pregnancy. |
|
Receive
|
12 (5.7%) |
… I voluntarily consent to receive medical and health care services that may include diagnostic procedures, examination, and treatment. |
