Informed Consent Order Form - Education

Patient Name: _____________________________________________________
Patient DOB: _____________________________________________________
Provider Name: _____________________________________________________

Please Obtain Informed Consent for the Following:

   Possible Only
Colon - Coloproctostomy/Colorectostomy (Noncancerous) (Robotic-Assisted Laparoscopic Possible Open) (20301)
This procedure involves removing the diseased or damaged part of the colon. Remaining parts of the colon will be joined together. The procedure...

Additional Notes (include Anatomical Side/Location if Applicable):

Order Form Accurate Until 11/2/2021