Hip Replacement Information and Consent Form
Name
First Name
Last Name
Email
example@example.com
Youtube
Section A: Clinical Understanding & Success
Patient Agreement: Total Hip ArthroplastyI understand that a hip replacement is a permanent surgical procedure and that my recovery depends on strict adherence to post-operative physiotherapy and weight-bearing restrictions until I receive formal clinical clearance from my surgeon. I acknowledge that while the procedure has a high success rate for restoring mobility and relieving pain (typically >90%), there are inherent long-term risks. These include a rare possibility of "late failure" (such as implant loosening, wear, or dislocation) or late-stage infection, which may occur years after the initial surgery and could necessitate further revision procedures.
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YES
Initial here:
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Section B: Specific Complication Disclosure
I have been informed of common post-operative risks, such as localized bruising and swelling, as well as the specific "material" risks associated with hip replacement. These include a risk of infection (~1–2%) and Venous Thromboembolism (blood clots), both of which may require prolonged medication or further surgery. I also acknowledge the risk of dislocation (1–3%), potential nerve injury causing temporary or permanent weakness, and the possibility of a leg length discrepancy, where the operated limb may feel or be slightly different in length compared to the other side.
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YES
Initial here:
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Section C: Legal Rights & GDPR (European Standard)
I confirm this decision is mine alone and made without pressure.I acknowledge that my personal and medical data is processed in accordance with GDPR regulations.I have had all my questions answered by the clinical team and understand that I can withdraw consent at any moment prior to the procedure.
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YES
Initial here:
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Submit
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