My physician has informed me of the planned operative procedure or medical treatment. The nature and purpose of the operative procedure or treatment, reasonable expectations, the most common side-effects, other treatment options, the specific risks involved, and the likelihood of complication, have all been explained to my satisfaction.  

Just as there may be benefits to the procedure(s) proposed, I also understand that the recommended medical care and surgical procedures involve risks. These risks include, but are not limited to: allergic reactions, bleeding, blood clots, infections, adverse side effects of drugs or anesthesia, brain injury, nerve injury, drug reactions, tooth damage, headache, and even loss of bodily function or life in rare cases.  I understand there is a risk of transfusion reactions and the transmission of infectious disease, including but not limited to Hepatitis and Acquired Immune Deficiency Syndrome, from the administration of blood and/or blood components which would only be used in the unlikely event where such transfusions were necessary to maintain my health.