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Spanish to English Haitian-Creole to French English to French Spanish to French Haitian-Creole to Spanish English to Spanish French to Spanish Haitian-Creole (monolingual) English (monolingual)
Source text - English TidalHealth Nanticoke
Consent to Surgical Operation,
Medical Procedure or Other Procedure
or Treatment
Patient :
DOB:
I have been told by Dr.
that I have diagnosis or condition:
and to treat this disease or condition I will require an operation/treatment/special procedure:
Moderate sedation for procedure by injection of medication–
intravenous sedation will be given for comfort during procedure
and I authorize the above doctor and any assistant under his/her supervision to perform the above.
I understand that unforeseeable circumstances during the course of the surgery or the procedure may require the physician named above or the associate to perform additional surgeries, treatments, or procedures.
I therefore consent to the performance of such additional surgery, treatments or procedures.
It has been explained to me by my physician in a way that I can understand: (a) the specifics of the proposed care, treatment, services, medications, interventions, or procedures; (b) potential benefits, risks, or side effects, including potential problems that might occur during recuperation; (c) the likelihood of achieving goals; (d) reasonable alternatives along with the relevant risks, benefits, and side effects; (e) and the possible results of not receiving care, treatment, and services.
In addition,
I understand specific risks of the surgery, procedure or treatment include, but are not limited to:
Oversedation resulting in decreased breathing; decreased blood pressure;
rare allergic or other reaction to medicines used.
Breathing or blood pressure complications are detected by monitoring during procedure
and treated as necessary.
Alternatives to this treatment are:
Performing the procedure without use of sedation.
Risks of no treatment include but are not limited to:
Pain during procedure; excessive anxiety; excessive motion threatening success of procedure.
I understand that desired results cannot be guaranteed.
I understand that unpredictable blood loss, infection, drug reaction, and heart or lung failure can occur in addition to the above specified risks.
I consent to any disposal method of removed tissue or body parts consistent with state and federal regulations.
I further agree that tissues or body parts removed may be examined or preserved for study in my care or the care of others.
I consent to the presence of students from professional health care training programs or technical advisors from an equipment or supply company during this procedure for the purposes of advancing medical education and care.
I authorize personnel to take photographs, motion pictures, video tape recordings, and other visual and/or auditory recordings of any surgical or other medical procedures performed upon me, provided my identity is not disclosed in any way.
I authorize subsequent use of this material for the advancement of medical science, education, and practice, including the use by other medical and educational institutions and professional groups.
I impose no specific limitation to my care except:
Sedation/anesthesia consent
I consent to the administration of anesthesia (general, spinal, regional, moderate sedation, local) by my attending physician, by an anesthesiologist, nurse anesthetist, or other licensed professional prior to procedure.
Risks and drawbacks, from general anesthetics range from minor discomfort to injury of vocal cords, teeth, or eyes.
I understand that other risks and drawbacks resulting from spinal or epidural anesthetics include headache and chronic pain.
I understand certain complications may result from the use of any anesthetic/sedation agent including respiratory problems, drug reaction, paralysis, brain damage or even death.
I have been informed of medical circumstances that may arise during the course of treatment that would necessitate a change in the method of administration of anesthesia or use of different types of anesthesia.
Patient :
DOB:
Blood consent/refusal
I understand there may be a need to transfuse me with blood and/or blood products during this procedure.
I have been informed of the risks and benefits of receiving such products and of alternative treatments available to me.
Those risks include but are not limited to: (a) Minor risks are uncommon, and may include: fever, headache or minor skin reactions such as bruising, itching, rash, swelling, or local infection at the site where the needle enters the skin; (b) The serious risks are rare, and include, but are not limited to: hemolytic reactions, kidney failure, heart failure, acute lung injury, and anemia; (c) Very rarely, transmission of infectious diseases can occur, including, but not limited to: hepatitis and HIV (the AIDS virus).
I understand that these risks exist despite the fact that the blood has been carefully tested by the Blood Bank.
No assurances or guarantees have been made to me about the outcome of the transfusion or the fitness or quality of the blood to be used.
Physician initials:
If blood or blood products are not anticipated for stated operation/procedure/treatment.
Patient limitations:
Patient initials:
I hereby consent to the administration of blood and/or blood products only if deemed necessary to save my life.
Patient initials:
I hereby refuse the administration of blood and/or blood products even in the event that the blood/blood products are deemed necessary to save my life.
My physician has explained to me the risks of refusing the administration of these products as well as alternative treatments, and I accept these risks.
Affirmation of informed consent by patient
This form has been translated into
By
to help me understand and consent for my operation, treatment or procedure.
I understand that the explanations I have received do not list everything that could happen, and that other problems may develop.
I know that no guarantee of success can be given.
My signature below indicates that: (a) I have read (or had read to me) and understand the information provided in this form; (b) that the operation or procedure set forth above has been adequately explained to me by my physician; (c) that I have had a chance to ask questions; (d) that I have received all of the information I desire concerning the operation or procedure; and (e) that I authorize and consent to the performance of the operation or the procedure identified above.
My signature is completely voluntary.
Signed:
Witness to signature
(Patient or person authorized to consent for patient)
Signed:
(If consent received by telephone,
(If not patient, relationship to patient)
Signature of monitoring witness is required)
Date
Time
Affirmation of informed consent by attending physician
I, the undersigned, attest to capacity of patient or appropriate decision-maker to give informed consent.
I have informed the above named patient, or the person authorized to extend consent on the patient’s behalf, of the medical condition requiring surgical treatment and/or the further diagnostic procedures referred to above.
I have explained the specifics of the proposed care, treatment, services, medications, intervention, or procedures along with potential benefits, risks, or side effects, including potential problems that might occur during recuperation.
The likelihood of achieving goals has been discussed
I have provided the patient with: (a) an explanation of reasonable alternatives; (b) the relevant risks, benefits, and side effects related to alternatives; (c) the possible results of not receiving care, treatment, and services.
Also discussed were any limitations on the confidentiality of information learned from or about the patient.
The patient was informed to an extent reasonably comprehensible to general lay understanding.
Signed:
Physician Date:
Time
NOTE:
Sedation or anesthesia will be used as part of this procedure.
Modern anesthesia is safe and patients usually tolerate it well
However, even in experienced and competent hands, complications can occur.
Therefore the professional performing the course of anesthesia must complete a separate consent:
THN-3415-F Informed Consent for Anesthesia
THN-501-1-F (4/22)
Back
THN-501-1-F (4/22)
Front
Translation - Haitian-Creole TidalHealth Nanticoke
Konsantman pou operasyon chirijikal,
Pwosedi Medikal oswa Lòt Pwosedi
oswa Tretman
Pasyan:
DAT NESANS
Dokte a te di mwen
ke mwen gen dyagnostik oswa maladi:
epi pou trete maladi oswa kondisyon sa a m pral mande pou yo fe m yon operasyon/tretman/pwosedi espesyal:
Mete sou kalman modere pou pwosedi pa enjeksyon medikaman -
yo pral bay piki kalman pou konfò pandan pwosedi a
epi mwen otorize doktè ki anwo a ak nenpòt asistan ki anba sipèvizyon li pou fè sa ki endike anwo a.
Mwen konprann ke sikonstans enprevisib pandan operasyon an oswa pwosedi a ka egzije doktè ki site pi wo a oswa asosye a fè lòt operasyon, tretman, oswa pwosedi.
Se poutèt sa mwen dakò pou fè operasyon adisyonèl, tretman oswa pwosedi sa yo.
Doktè mwen an te eksplike m sa yon fason ke mwen ka konprann: (a) detay swen, tretman, sèvis, medikaman, entèvansyon, oswa pwosedi yo pwopoze yo; (b) benefis potansyèl, risk, oswa efè segondè, ki gen ladan pwoblèm potansyèl ki ta ka rive pandan rekiperasyon an; (c) chans pou reyalize objektif yo; (d) altènativ rezonab ansanm ak risk, benefis ak efè segondè ki enpòtan yo; (e) ak rezilta posib si yo pa resevwa swen, tretman ak sèvis yo.
An plis,
Mwen konprann risk espesifik nan operasyon, pwosedi oswa tretman an ki gen ladan, men yo pa limite a:
Twòp kalman ki lakòz respirasyon diminye; tansyon desann;
alèji ki ra oswa lòt reyaksyon a medikaman yo itilize.
Konplikasyon respirasyon oswa tansyon yo detekte le y ap siveye pandan pwosedi a
epi trete jan sa nesesè.
Altènatif nan tretman sa a se:
Fè pwosedi a san yo pa itilize kalman.
Risk pou pa gen okenn tretman gen ladan men yo pa limite a:
Doulè pandan pwosedi a; twòp enkyetid; twòp mouvman menase reyisit pwosedi a.
Mwen konprann ke rezilta yo vle yo pa ka garanti.
Mwen konprann ke pèt san enprevizib, enfeksyon, reyaksyon dwòg, ak kè oswa poumon ki pa fonksyone byen ka rive anplis risk ki espesifye anwo yo.
Mwen dakò ak tout metòd eliminasyon tisi oswa pati nan kò yo retire ki konsistan avèk règleman leta ak federal yo.
Anplis de sa, mwen dakò ke tisi oswa pati kò yo retire yo ka egzamine oswa konsève pou etid nan swen mwen oswa swen lòt moun.
Mwen dakò pou prezans etidyan ki soti nan pwogram fòmasyon pwofesyonèl swen sante oswa konseye teknik nan yon konpayi ekipman oswa founiti pandan pwosedi sa a nan objektif pou avansman edikasyon ak swen medikal.
Mwen otorize pèsonèl yo pran foto, foto deplasman, anrejistreman videyo, ak lòt anrejistreman vizyèl ak/oswa oditif nenpòt pwosedi chirijikal oswa lòt pwosedi medikal ki fèt sou mwen, depi yo pa divilge idantite mwen nan okenn fason.
Mwen otorize itilizasyon materyèl sa a apre pou avansman syans medikal, edikasyon, ak pratik, ki gen ladan itilizasyon lòt enstitisyon medikal ak edikasyon ak gwoup pwofesyonèl.
Mwen pa enpoze okenn limit espesifik nan swen mwen eksepte:
Konsantman anestezi /kalman
Mwen dakò pou administrasyon anestezi (jeneral, epinyè, rejyonal, kalman modere, lokal) pa doktè mwen an ki prezan , pa yon anestezis, yon enfimyè anestezi, oswa yon lòt pwofesyonèl ki lisansye anvan pwosedi a.
Risk ak dezavantaj, nan anestezi jeneral yo varye soti nan ti malèz rive nan blesi nan kòd vokal, dan, oswa je.
Mwen konprann ke lòt risk ak dezavantaj ki soti nan anestezi epinyè oswa epidiral gen ladan tèt fè mal ak doulè kwonik.
Mwen konprann sèten konplikasyon ka soti nan itilizasyon nenpòt ajan anestezi/kalman ki gen ladan pwoblèm respiratwa, reyaksyon dwòg, paralizi, domaj nan sèvo oswa menm lanmò.
Yo te enfòme m sou sikonstans medikal ki ka rive pandan tretman an ki ta bezwen yon chanjman nan metòd administrasyon anestezi oswa itilizasyon diferan kalte anestezi.
Pasyan:
DAT NESANS
konsantman/refi san
Mwen konprann ke ka gen yon bezwen pou banm yon transfizyon san ak/oswa pwodwi san pandan pwosedi sa a.
Yo te enfòme m sou risk ak benefis ki genyen nan resevwa pwodui sa yo ak tretman altènatif ki disponib pou mwen.
Risk sa yo gen landan yo men pa limite a: (a) Ti risk yo pa komen, epi yo ka gen ladan: lafyèv, maltèt oswa ti reyaksyon po tankou ematom, demanjezon po, gratèl, gonfleman, oswa enfeksyon lokal kote zegwi a antre nan po a. ; (b) Risk grav yo ra, epi yo gen landan yo, men yo pa limite a: reyaksyon emolitik, ensifizans renal, ensifizans kadyak, blesi nan poumon egi, ak anemi; (c) Trè raman, transmisyon maladi enfektyez ka rive, ki gen ladan, men pa limite a: epatit ak VIH (viris SIDA).
Mwen konprann ke risk sa yo egziste malgre lefèt Bank san an te byen teste l.
Pa gen okenn asirans oswa garanti yo te ban m sou rezilta transfizyon an oswa aptitid oswa kalite san an yo dwe itilize.
Inisyal doktè:
Si yo pa prevwa san oswa pwodwi san yo pou operasyon/pwosedi/tretman ki endike yo.
Limit pasyan yo:
Inisyal Pasyan an _____
Mwen dakò pou yo ban mwen san ak/oswa pwodwi san yo sèlman si mwen jije li nesesè pou sove lavi m.
Inisyal Pasyan an _____
Mwen refize pran san ak/oswa pwodwi san yo menm si yo jije san/pwodwi san yo nesesè pou sove lavi m.
Doktè mwen te eksplike m risk ki genyen nan refize yo administre pwodui sa yo banm ak tretman altènatif, epi mwen aksepte risk sa yo.
Afimasyon konsantman pasyan fè konnen
Fòm sa a te tradui
pa
pou ede m konprann epi dakò pou operasyon, tretman oswa pwosedi mwen an.
Mwen konprann eksplikasyon mwen te resevwa yo pa gen ladan yo tout sa ki ka rive, e ka gen lòt pwoblèm ki devlope.
Mwen konnen yo pa ka bay okenn garanti siksè.
Siyati mwen anba a endike: (a) Mwen te li (oswa yo te li pou mwen) epi mwen konprann enfòmasyon yo bay nan fòm sa a; (b) operasyon an oswa doktè mwen te byen eksplike m pwosedi ki endike anwo ; (c) mwen te gen yon chans poze kesyon; (d) mwen te resevwa tout enfòmasyon mwen vle konsènan operasyon an oswa pwosedi a; epi (e) mwen otorize e mwen dako pou yo fè operasyon an oswa pwosedi yo idantifye pi wo a.
Siyati mwen an konplètman volontè.
Siyen la
Temwen Siyati a
(Pasyan oswa moun ki otorize bay konsantman pou pasyan an)
Siyen la
(Si yo resevwa konsantman pa telefòn,
(Si non pasyan, relasyon ak pasyan)
Siyati temwen k ap siveye a obligatwa)
Dat
Lè
Doktè ki asiste afimasyon konsantman yo fe konnen an
Mwen menm ki siyen an, sètifye kapasite pasyan an oswa moun k ap pran desizyon ki apwopriye pou bay konsantman l enfòme a.
Mwen te enfòme pasyan ki endike anwo a, oswa moun ki otorize pou bay konsantman an nan non pasyan an, sou kondisyon medikal k ap mande tretman chirijikal ak/oswa lòt pwosedi dyagnostik yo mansyone pi wo a.
Mwen eksplike detay swen, tretman, sèvis, medikaman, entèvansyon, oswa pwosedi yo pwopoze yo ansanm ak benefis potansyèl, risk, oswa efè segondè yo, ki gen ladan pwoblèm potansyèl ki ta ka rive pandan rekiperasyon an.
Yo te diskite sou chans pou yo atenn objektif yo
Mwen bay pasyan an: (a) yon eksplikasyon sou altènativ rezonab; (b) risk, benefis, ak efè segondè ki gen rapò ak altènativ yo; (c) rezilta posib si yo pa resevwa swen, tretman ak sèvis yo.
Yo te diskite tou nenpòt limit sou konfidansyalite enfòmasyon yo aprann nan men oswa sou pasyan an.
Yo te enfòme pasyan an nan yon limit konpreyansib rezonab jiska konpreyansyon jeneral yon pwofan.
Siyen la
Dat Doktè bay:
Lè
NÒT:
Yo pral itilize kalman oswa anestezi kòm yon pati nan pwosedi sa a.
Pa gen pwoblèm ak anestezi modèn epi anjeneral pasyan yo sipote li byen
Sepandan, menm nan men moun ki gen eksperyans ak konpetans, ka gen konplikasyon.
Se poutèt sa, pwofesyonèl k ap fè travay anestezi a dwe ranpli yon fomilè konsantman separe:
THN-3415-F Konsantman Enfòme pou Anestezi
THN-501-1-F (22/4)
Fè bak
THN-501-1-F (22/4)
Devan
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Bachelor's degree - Bchelor's degree
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Years of experience: 26. Registered at ProZ.com: Jul 2018. Became a member: Apr 2023.
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Bio
As an Interpreter/Translator, I started to do freelance work in the field back in 1998 for a non-profit organizasion which name is Christian Service International (CSI) and at the same time for another one, known under the name of Methodist Guest House; for both of those companies I would do interpreting and tranlation work for them and as time went by, I found the opportunity to work as an Interpreter/Translator for the United Nations Mission for the Stabilization in Haiti (MINUSTAH). I spent more than 12 years working in the UN and I can tell that I really enjoyed the experience because it allowed to meet people from different background speaking different languages.
Therefore, over all the past years, I have had the opportunities to earn various credentials in the field and following my tenure, I left the UN in 2017 and ever since that time, I have always been working as a freelancer providing my services to a wide range of companies such as : Global Language Strategies, USEA, Transperfect, Lionbridge, Unity Language Services, Propio, Jeenie, Boostlingo, Day Translation, Trusted Translation, STEPES, and the list goes on....
I think that when it comes to experience, competence and qualifications, I can be a very great assistance to any company willing to benefit from my services (translation and interpreting).
Member since Apr '23
