Informed Consent for Bariatric (Weight Loss) Surgery

Procedure Name

Form Sections

Section 1info grid

Surgical Facility Name

Attending Bariatric Surgeon

Patient Full Legal Name

Date of Birth

Medical Record Number (MRN)

Planned Bariatric Procedure

Anesthesia Method

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Section 3list block

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Section 12signature block

Patient / Authorized Representative Signature

Witness Signature (If Required)

Attending Surgeon Signature

Informed Consent for Bariatric (Weight Loss) Surgery

Patient and Facility Information

Surgical Facility Name

Attending Bariatric Surgeon

Patient Full Legal Name

Date of Birth

Medical Record Number (MRN)

Planned Bariatric Procedure

Anesthesia Method

Nature and Purpose of the Procedure

Bariatric surgery is performed to assist with significant weight loss and manage obesity-related health conditions (such as type 2 diabetes, severe sleep apnea, and hypertension). The surgical procedure, which may restrict stomach size or alter the digestive pathway, is performed under general anesthesia. The surgeon will discuss the specific surgical methods (including laparoscopic or robotic approaches) prior to the procedure. The clinical objective is to modify gastrointestinal anatomy to support metabolic health.

Material Risks and Potential Complications

Anastomotic leak or staple line leak: leakage of digestive fluids from the connections in the stomach or bowel, which is a serious complication that may require immediate surgery, drainage, and long-term IV therapy.

Bleeding or hematoma formation along the staple lines or surgical incisions, potentially requiring blood transfusion or repeat surgery.

Infection: superficial wound infection or deep abdominal abscess, requiring drainage and antibiotics.

Nutritional deficiencies: permanent or long-term malabsorption of vitamins and minerals, requiring lifelong supplementation and regular blood monitoring.

Dumping syndrome: rapid emptying of stomach contents into the small intestine, causing nausea, abdominal cramps, diarrhea, sweating, and dizziness.

Bowel obstruction, stricture formation, or gallstone development, which may require secondary surgical procedures.

Expected Benefits

Expected benefits include substantial and long-term weight reduction, improvement or complete resolution of obesity-associated comorbidities (such as type 2 diabetes, high blood pressure, and obstructive sleep apnea), and improvement in overall physical function.

Reasonable Alternatives

Non-surgical weight management programs, including medical weight loss, nutritional counseling, and behavior therapy.

Pharmacological weight loss therapies under the supervision of a physician.

Choosing not to proceed with bariatric surgery and maintaining current weight management protocols.

Consent for Anesthesia Services

I understand that anesthesia services are needed for this procedure. The anesthesia provider will separately explain the risks, benefits, and alternatives of the specific anesthesia plan (e.g., general, regional, or local sedation) and obtain separate consent.

Consent for Blood Transfusion

I understand that during this procedure, significant blood loss may occur. If my physician determines it is medically necessary to preserve my life or health, I consent to the administration of blood or blood products.

Tissue Disposal and Pathology

I authorize the medical facility to retain, preserve, use for educational purposes, or dispose of any tissue, fluid, or body parts removed during the procedure in accordance with standard medical practices and legal requirements.

Photography and Observer Consent

I consent to the photographing or video recording of the procedure for medical, scientific, or educational purposes, provided my identity is not revealed. I also consent to the presence of medical students, residents, or device manufacturer representatives as approved by my surgeon.

No Guarantees

I acknowledge that the practice of medicine and surgery is not an exact science. I understand that no guarantees or assurances have been made to me regarding the outcomes or results of this procedure.

Patient Acknowledgment and Consent

I certify that I have read and fully understand this consent form. My physician has explained the procedure, its risks, benefits, and alternatives. I have had all my questions answered to my satisfaction, and I voluntarily consent to the proposed treatment.

Signatures and Verification

Patient / Authorized Representative Signature

Witness Signature (If Required)

Attending Surgeon Signature

Document ID: CC-PENDING

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