I hereby give my consent and authorize Doctor 
ol The Johni Hopkins Hospital to perform the following operation or other procedure: 
RIGHT OR LEFT RADICAL NEPHRECTOMY 
Identify and explain in non medical terms, use no abbreviations 
I acknowledge that : 
1. The nature and purpose of the operation or other procedure and anesthesia, the risks involved, alternatives and the possibility of complicat 
have been explained to me by Doctor MARSHALL and all my questions, if any, have been answered tc 
satisfaction I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantee has been made as 
the results that may be obtained. 
2. I consent to the performance of the above-named operation or other procedure and if, during the contemplated operation or other procec 
other conditions are discovered which, in the best judgment of the medical staff of The Johns Hopkins Hospital, require an extension of the oric 
contemplated operation or other procedure or a different operation or other procedure. I authorize and request that the said operation or o 
procedure be performed. 
3. I further consent to the administration of such anesthesia as may be considered necessary or advisable in the judgment of the medical staf 
The Johns Hopkins Hospital. 
4. Exceptions to surgery or anesthesia, if any. are: NONE 
(If "none", so state) 
5. I consent to the disposal by authorities of The Johns Hopkins Hospital of any tissues or parts which it may be necessary to remove. I authc 
The Johns Hopkins Hospital to retain, preserve, and use for scientific or teaching purposes any tissue or specimens taken from my body. 
6. I consent to the admittance of observers, in accordance with ordinary practices of The Johns Hopkins Hospital, to the uie of closed-cir 
television, the taking of photographs (including motion pictures), and the preparation of drawings and similar illustrative graphic material, an 
also consent to the use of such photographs and other materials for scientific purposes, provided my identity is not revealed by the pictures or 
the descriptive text accompanying them. 
7 The undersigned acknowledges receipt of a copy of the foregoing consent and authorization to an operation or other procedure. 
Witness's Signature 
Signature of Physician Securing Consent 
Patient's Signature 
JHHIDNO. □□□□□[! 
IF PATIENT IS UNABLE TO SIGN OR IS A MINOR. COMPLETE THE FOLLOWING: 
Patientlis a minor years of age) or is unable to sign because: 
Witness's Signature 
C'o„st Relative or Legal Guardian's Signature 
JHH 15-144020 
R42] 
Recon. binant DNA Research, Volume 17 
