Laser Hemorrhoid Consent Form

I, the undersigned patient, hereby consent to undergo laser hemorrhoid treatment (laser hemorrhoidectomy) under the care of Dr. at . I have been provided with information about this procedure, including its benefits, potential risks, and alternatives.

Laser hemorrhoid treatment is a medical procedure used to address symptomatic hemorrhoids. During the procedure, a laser is used to vaporize or coagulate hemorrhoidal tissue, leading to reduced swelling and discomfort. The potential benefits of laser hemorrhoid treatment include relief from pain, bleeding, and discomfort associated with hemorrhoids.

I understand that, like any medical procedure, laser hemorrhoid treatment carries certain risks, including but not limited to:

• Pain, discomfort, or irritation after the procedure.
• Infection at the treatment site.
• Bleeding, although minimal, may occur during or after the procedure.
• In rare cases, scarring or damage to nearby tissues may occur.
• Allergic reactions to anesthesia or medications used during the procedure.

I have been informed about alternative treatment options for hemorrhoids, including conservative management, dietary and lifestyle modifications, and other medical and surgical interventions.

I have had the opportunity to ask questions and discuss this option with my healthcare provider.

I have read and understood the information provided above regarding the laser hemorrhoid treatment. I have had the opportunity to ask questions and have them answered to my satisfaction. I consent to undergo the laser hemorrhoid treatment as described, understanding both the potential benefits and risks associated with the procedure.

I understand and agree that I am financially responsible for the payment I made for and that any amount I paid for the sessions or procedures I booked will only be valid up to 3 months from the date I made the payment. I understand that I need to utilize the sessions or procedures within the 3-month period. I agree that my payment made is non-refundable or non-transferable post this period.

I declare that I have read and fully understood all points in this consent and that all of my questions were answered to my satisfaction and I take full responsibility for my decision in this consent.