Free Advance Statement Template
Advance Statement
I. Introduction
This Advance Statement serves as a directive for healthcare providers involved in the surgery or medical procedures of [Patient Name]. It delineates my preferences and instructions concerning anesthesia, surgical methods, and post-operative care, ensuring that my medical care respects my decisions during times when I might not be able to communicate them directly.
II. Patient Information
|
Patient Information |
Details |
|---|---|
|
Patients Name |
[Patient Full Name] |
|
Patient ID |
[Patient ID Number] |
|
Date of Birth |
[Date Of Birth] |
|
Primary Care Physician |
[Doctor's Name] |
|
Contact Information |
[Contact Information] |
III. Surgical Procedure Details
Description of the planned surgical procedure(s): [Description of Procedure]
Date and Location of Procedure:
-
Date: [Date of Procedure]
-
Location: [Hospital or Clinic Name]
IV. Anesthesia Preferences
Type of anesthesia requested (if any specific preference exists): [Preferred Anesthesia Type]. This choice has been discussed and agreed upon with the anesthesiologist: [Anesthesiologist's Name], considering the medical suitability and potential risks.
V. Post-Operative Care Instructions
Key instructions for post-operative care:
|
Patient Information |
Details |
|---|---|
|
Pain Management Plan |
[Pain Management Details] |
|
Dietary Restrictions/Preferences |
[Dietary Needs] |
|
Physical Therapy Requirements |
[Physical Therapy Needs] |
|
Special Medical Equipment Needed |
[Medical Equipment] |
|
Follow-up Medical Check-up Date |
[Follow-up Date] |
VI. Emergency Contacts
In case of an emergency during or following the procedure, listed below are the contacts to be notified:
-
Primary Emergency Contact: [Emergency Contact Name] - Phone: [Emergency Contact Phone]
-
Secondary Contact: [Secondary Contact Name] - Phone: [Secondary Contact Phone]
VII. Legal Acknowledgment
This statement is made voluntarily to guide my healthcare providers in following my wishes. All information disclosed herein is accurate to the best of my knowledge. I understand that I can modify this directive at any time, providing that any changes are communicated in a signed and dated written document.
[Patient Name]
[Date]
