REPUBLIC OF TURKEY

MINISTRY OF HEALTH
Health Sciences University Kartal Dr. Lütfi Kırdar Training and Research Hospital
ANESTHESIOLOGY AND REANIMATION CLINICS INFORMED CONSENT FORM
CODE DATE OF ISSUE REVISION NO DATE OF REVISION PAGE NUMBER/PAPAER COUNT
YN.RB.117 15.08.2008 05 08.01.2018 1/2
Name-Surname of the
patient
Date of Birth

Identity Number

DEAR PATIENT AND PATIENT RELATIVE PLEASE READ THIS DOCUMENT CAREFULLY.
You Have Been Examined By Dr.…………………………………From Anesthesiology And Reanimation Clinic to have operation
for………………………………………………………………. and It Is Found Appropriate For You To
have…………………………………………………………… Anesthesia method.

INFORMING OF PATIENT/PATIENT REPRESENTATIVE ABOUT ANESTHESIA

ANESTHESIA TYPES
1.General Anesthesia:
It makes you unconscious by the use of different medicines at the right dose and it helps you not to feel pain during the surgery.
During the surgery, various medicines are given at different times for special purposes. Medicines are injected into the blood through a
vascular access and are breathed into your lungs as gas or steam. The breathing tube is placed under the anesthesia to help you breathe
from your breathing pipe. This tube is removed when you are waking up after the operation is over. Important findings related to the organs
(pulse, blood pressure, respiratory blood oxygenation, heart rate, ECG etc.) are continuously monitored during the anesthesia. If necessary,
interventional procedures (such as placing of cannula into large vessels-arterial cannulation, central venous catheterization) may be applied.
2. Local Anesthesia, Spinal and Epidural Anesthesia
If this method is applied, you can stay awake during the surgery. If needed or desired, sedative medicines may be given to you. Local
anesthesia may be in the form of peripheral nerve blocks, spinal and epidural, and combined spinal-epidural anesthesia. Local anesthetic
medicines, and sometimes pain killers are applied from your back region to anesthetize a large part of your body. These techniques can be
used to remove the pain during surgery and then to reduce the pain. Local anesthetics can be applied as nerve blocks to anesthetize a
smaller area, such as the operation site, or to anesthetize a larger area of operation such as the chest, abdomen, arms, legs and eyes. Local
anesthetics can also be used together with general anesthesia. As exactly the same way in general anesthesia, the important organ findings
of the body are continuously monitored with the help of devices.
In some rare cases, anesthesia initiated by local methods (spinal, epidural or nerve blocks) may have to be continued by general
anesthesia. (For reasons such as duration of surgery taken longer than estimated time, properties of medicines and materials used, and
patient-induced causes).

RISKS OF ANESTHESIA
General Risks of Anesthesia
Modern anesthesia is generally very safe. The risk of an unexpected death of a healthy person during anesthesia is less than the risk of
death in a car accident. However, there are risks definitely. Undesirable side effects are generally temporary, some of them cause long term
problems rarely.

Frequent undesirable side effects: nausea and/or vomiting, headache, pain, redness swelling or burning in the injection site, painful or dry
throat or lips, blurred or double vision.

Infrequent undesirable side effects: muscle pains, weakness, moderate level of allergic reaction - such as itching or rash.
Rare undesirable side effects: Awareness under general anesthesia, dental prosthesis, injury of tongue and lips, vocal cord damage that
may cause temporary hoarseness or loss, allergic reactions and/or asthma, constriction of the respiratory tract, blood clots in the legs,
damage to nerves and pressure fields, epileptic seizure, atelectasis due to interventional procedures such as placing of cannula into large
vessels, collection of blood outside the vessel.

Rare risks that may cause to death: Such as severe allergy and shock (stroke) or heart attack, brain damage, very high fever, vomiting in
the lungs, pneumonia, blood clots came into the vessels in the lungs.

Conditions that increase the risks of anesthesia: Such as old age, smoking, alcohol use, diabetes-kidney-liver-cardiovascular and
nervous system diseases, high blood pressure, being overweight, a bad cold or flu, asthma or other chest diseases, infection (septicemia) or
other serious medical illnesses.

Local Anesthesia, Peripheral Nerve Blocks, Spinal and Epidural and Combined Spinal-epidural Anesthesia Risks: Nerve damage,
bleeding, infection and other causes are the specific risks, which are added to the local anesthesia. This can cause numbness and/or
weakness in the body area where the nerve goes. This situation is usually moderate and temporary.
Special Risks Added to Spinal and Epidural Anesthesia:
a) Rarely, it may cause serious and permanent nerve damage. It may cause paralysis in the lower half of the body (paraplegia or paralysis
(quadriplegia) in the entire body.
b) Rarely, it may cause damage in surrounding tissues such as blood vessels, lungs.
c) Headache is usually temporary. But it may be severe or last for days
d) Back pain is a temporary condition that generally causes burning around the injection site, and may rarely last long.
e) Infection in implementation area of the process or a widespread infection may develop.

Estimated time of the process: ………………………………………………………………………

 REPUBLIC OF TURKEY
MINISTRY OF HEALTH
Health Sciences University Kartal Dr. Lütfi Kırdar Training and Research Hospital
ANESTHESIOLOGY AND REANIMATION CLINICS INFORMED CONSENT FORM
CODE DATE OF ISSUE REVISION NO DATE OF REVISION PAGE NUMBER/PAPAER COUNT
YN.RB.117 15.08.2008 05 08.01.2018 2/2
Name-Surname of the
patient
Date of Birth

Identity Number

Alternatives of the process, if any………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………
Important Properties of Medicines Used: ……………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………
Potential benefits and risks that may arise in case of rejection of process. ……………………………………………………
……………………………………………………………………………………………………………………………………………………
Lifestyle recommendations that are critical to your health: ……………………………………………………
……………………………………………………………………………………………………………………………………………………
If necessary, you can get medical help on the same topic from .......................…………………………………………………
CONSENT OF PATIENT/PATIENT REPRESENTATIVE

The anesthesia method …………………………..suggested by the doctor due to the medical condition and the diagnosis of my illness
.............................. was explained to me, and the factors that increase these risks were told me.

I have understood all the risks, possible complications, and the consequences that they may result in, as well as those that are specific to me. I
was informed about the possible use of medications and possible side effects. The life-threatening situations that can occur suddenly during
anesthesia and treatment methods were told to me. I have asked my questions and told my doubts to the doctor about my situation, the
methods and their risks. My questions and doubts were discussed and answered satisfactorily. I know that other doctor/doctors and anesthesia
technicians other than the doctor, who will perform the anesthesia procedure, may also enter into the operation. I am aware also that assistant
doctors also will be within the anesthesia team because the hospital, in which I will be operated, is an Education and Research Hospital.
I AGREE that important organ findings (pulse, blood pressure, respiration, blood oxygenation, heart beats, ECG etc.) will be continuously
monitored with the help of devices during the planned anesthesia implementation; as well as interventional procedures (such as placing of
cannula into large vessels - arterial cannulation, central venous catheterization) may be applied if found necessary for my health during the
planned anesthesia application.
I AGREE that the anesthesia application can be applied by an anesthesia team, in which the doctor, whose name is written
below or another anesthesia doctor will be involved. I know the meaning of the consent form that I signed. It was told that I
can withdraw (cancel) this consent form at any time.
In the light of the above explanations made in the way that I could understand the entire of it, I UNDERSTOOD THE RISKS THAT
MAY OCCUR DURING THE ANESTHESIA. I COMPLETELY AGREE THE APPLICATION OF ANESTHESIA WITH MY FREE
WILL.

PLEASE FILL THE FOLLOWING FIELDS HANDLY.

IF THE PATIENT IS CONSCIOUS
Please write in the below space the following expression:
*(I have read hereby informing and consent form/ my relative has
read to me and I have understood) and
*(I have received one copy by hand)
IF THE PATIENT IS UNCONSCIOUS
Please write in the below space the following expression:
*(I have read hereby informing and consent form/ my relative has
read to me and I have understood) and
*(I have received one copy by hand)

Patient’s Legal Representative (Guardian) and/or Parent

Name&Surname Name&Surname:
Phone Number.:..........................................................
Phone Number............................... Signature:
Signature:
Doctor Doctor
Name Surname: Name Surname:
Signature: Signature:

Date/Hour of Receipt of the Consent: Date/Hour of Receipt of the Consent :

Note:
1- The patient is younger than 18 years old and his/her conscious is closed or he/she does not have signing
authority, consent is given by his/her representative.
Hereby form shall be filled in 2 copies and one copy shall remain in the patient.

SCOPE OF REVISION: The name of Hospital was revised as T.R. Ministry of Health Health Sciences University
Kartal Dr. Lütfi Kırdar Training and Research Hospital.
 REPUBLIC OF TURKEY
MINISTRY OF HEALTH
Health Sciences University Kartal Dr. Lütfi Kırdar Training and Research Hospital
Plastic Surgery Clinic
INFORMED PATIENT CONSENT FORM FOR SCAR OPERATION

CODE DATE OF ISSUE REVISION NO DATE OF REVISION PAGE NUMBER/PAPAER COUNT

YN.RB.207 15.08.2008 04 08.01.2018 1/3
Name-Surname of the
patient
Date of Birth

Identity Number

Hereby form was prepared to inform patients and their relatives about the operation to be performed. It is a legal obligation to have it
read and approved. Information forms are used to explain the risk and undesirable conditions (complications) of the surgical
treatments; and to give information about other treatment options. The identified risks are described to meet the needs of most
patients in many conditions. However, hereby form should not be considered as a document containing the risks of all methods of
treatment. Depending on your personal health condition or medical information, your plastic surgeon may give you different
information or additional information.

Do not sign the form on the last page without carefully reading all the information below and finding answers to all your
questions.

OPERATION TO BE PERFORMED
Removal of scars, which have been previously formed in the body due to physical injury, from the body, and stitching them
again if appropriate or closing them with the methods of using skin patches from other areas of the body or special
substances compatible with the tissue.

PREOPERATIVE
• You are a smoker, you must stop smoking two weeks before the surgery and two weeks after the surgery.
• A cold or other infection may cause to postpone the surgery.
• Antiaggregant agents such as aspirin should be avoided for 10 days before the surgery.
• Important diseases in your past and the medicines that you use regularly must be informed to your doctor.
• Soft foods should be taken for 3-4 days before the surgery, and pulpy food should be avoided. Avoid heavy diets before the
surgery.
• You should not eat anything after the specific hour that was informed you. This period covers the 6 hours before the
surgery.

ANESTHESIA (NARCOSIS)
Blood tests, that are necessary for you, shall be performed on or before the surgery day. In the same way, your anesthesia
consultation shall be made in the preoperative period and the anesthesia pattern to be applied to you shall be decided.
For information on the risks of anesthesia and the anesthetic substance, please see the "anesthesia information form". If you
have any concerns about this matter, see your anesthesiologist.
If the information form is not given, ask it from your anesthesiologist.

RISKS RELATED TO THE METHOD

a) During or after surgery, blood loss may occur, and fluid replacement or blood transfusion may be required.
b) Debridement of the scar tissue may cause the infection pass into the blood and serious toxic effects.
c) If skin transplant is required;
• The skin transplantation may not work.
• Skin transplantation may not resemble the normal tissue
• The color of the skin transplantation may be different from the other parts of the skin.
d) In the area, from which the skin transplantation was taken;
• There may be bleeding for a while. This fluid may be required to be drained.
• Recovery may be slow.
• Painful, thickened and color different tissue may be seen as a result of healing.
e) Scar areas with or without skin transplantation may heal by thickening of the tissues, and there may be contractions
within the tissues sometimes.
f) The trace will never disappear completely.

MEDICAL STATEMENT
I have explained
• The condition of the patient
• Patient’s requirements for treatment
• The operation process and its risks
• Relevant treatment options and their risks
• The results in case the risk occurs,
• Specific significant risks and consequences that vary from patient to patient
And I have given opportunity
• For the patient to ask questions about the above matters
For the patient/the person who will decide for the patient to remove any concerns;
I think that the patient/the person who will decide for the patient has understood the above information.
 REPUBLIC OF TURKEY
MINISTRY OF HEALTH
Health Sciences University Kartal Dr. Lütfi Kırdar Training and Research Hospital
Plastic Surgery Clinic
INFORMED PATIENT CONSENT FORM FOR SCAR OPERATION

CODE DATE OF ISSUE REVISION NO DATE OF REVISION PAGE NUMBER/PAPAER COUNT

YN.RB.207 15.08.2008 04 08.01.2018 2/3
Name-Surname of the
patient
Date of Birth

Identity Number

CONSENT OF PATIENT
My doctor have told me about my problems, the type of treatment, the surgery, the alternative therapies realted to this, and
the risks and complications that I may encounter. My doctor has given me the opportunity to ask any questions I have had o n
my mind.
I have understood that serum and blood may be given to me if required during the surgery.
I have understood that, during the surgery; I understand that any excess can be removed, and tissues and organs can be
taken for being used in another area (called graft or flap), or for pathological examination.
I have understood that the surgical traces will remain after surgery, and they will not disappear for lifetime. I agree to make
any suggestions (massage with special creams, application of silicone sheets) to keep these marks in the least and good
condition.
I know that smoking cigarettes before and after the surgery negatively affects blood circulation and wound healing, and that it
may cause undesirable results.
I have understood that the necessary initiatives (grinding, stripping with chemicals, small excisions (cuts)) may be done in
surgery in order to get better results.
I allow necessary medical pictures and videos to be taken before, during and after the surgery. I know that these pictures and
videos may be shown to other doctors for medical and scientific purposes.
I know that there are risks in connection also with general anesthesia, and that they are under the responsibility of the
anesthesiologist, and that there will be additional explanations and forms will have been signed related to these.
I have also understood that additional interventions may be made in an emergency situation that threatens life during surgery.
As a result, I have also understood that this surgery is not a guarantee for improvement of the present situation, and there is
the possibility that the expected result may not be achieved for various reasons, and that even worse results than my current
situation may occur.

I have understood and agreed that a team consisting of specialist and assistant doctors of T.R. Ministry of Health Health Sciences
University Kartal Dr. Lütfi Kırdar Training and Research Hospital shall perform my surgery and that this hospital is a “Training
Hospital” and some or all of the surgical procedures may be performed by assistant doctors under the supervision of a specialist
doctors if required.

I have read all of the above information and also a lot of other verbal information was provided to me. On the other hand, I have told
my doctor about the diseases, surgeries I have had till today as well as the medications and substances I have used and been using,
and all the required information about myself and my family. I stated that I am satisfied with the verbal and written statements made
to my side. I give my consent, as conscious and with my own will, to the treatment and surgery to be made as well as to all the
treatments to be made in situations that may occur later, and to the items listed above and to the verbal explanations made to me at
the same time and I want this treatment.

I have understood all what is told me.

My doctor answered all my questions.
I know the meaning of the informed consent form.
I know who will interfere with me.
"I have decided with my free will.

Estimated time of the operation

Potential benefits and risks that may arise in case of rejection of process:………………………………………………………
………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………
Lifestyle recommendations that are critical to your health:………………………………………………………………………..
………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………….
If necessary, you can get medical help on the same topic from ……………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………
 REPUBLIC OF TURKEY
MINISTRY OF HEALTH
Health Sciences University Kartal Dr. Lütfi Kırdar Training and Research Hospital
Plastic Surgery Clinic
INFORMED PATIENT CONSENT FORM FOR SCAR OPERATION

CODE DATE OF ISSUE REVISION NO DATE OF REVISION PAGE NUMBER/PAPAER COUNT

YN.RB.207 15.08.2008 04 08.01.2018 3/3
Name-Surname of the
patient
Date of Birth

Identity Number

PLEASE FILL THE FOLLOWING FIELDS HANDLY.

IF THE PATIENT IS CONSCIOUS IF THE PATIENT IS UNCONSCIOUS

Please write in the below space the following expression: Please write in the below space the following expression:
*(I have read hereby informing and consent form/ my relative has *(I have read hereby informing and consent form/ my relative has
read to me and I have understood) and read to me and I have understood) and
*(I have received one copy by hand) *(I have received one copy by hand)

Patient’s
Legal Representative (Guardian) and/or Parent
Name&Surname
Name&Surname:
Phone Number.:..........................................................
Phone Number...............................
Signature:
Signature:

Doctor Doctor
Name Surname: Name Surname:
Signature: Signature:

Date/Hour of Receipt of the Consent: Date/Hour of Receipt of the Consent :

Note:
1- The patient is younger than 18 years old and his/her conscious is closed or he/she does not have signing authority, consent is
given by his/her representative.
2- Hereby form shall be filled in 2 copies and one copy shall remain in the patient.

SCOPE OF REVISION: The name of Hospital was revised as T.R. Ministry of Health Health Sciences
University Kartal Dr. Lütfi Kırdar Training and Research Hospital.
 REPUBLIC OF TURKEY
MINISTRY OF HEALTH
Health Sciences University Kartal Dr. Lütfi Kırdar Training and Research Hospital
INFORMED PATIENT CONSENT FORM FOR CHEMOTHERAPY
CODE DATE OF ISSUE REVISION NO DATE OF REVISION PAGE NUMBER/PAPAER COUNT
YN.RB. 311 15.08.2008 04 08.01.2018 1/2
Name-Surname of the
patient
Date of Birth

Identity Number

Dear…………………………………………………………;

Because of your illness, you need to have chemotherapy. Chemotherapy is the oral administration of drugs
and / or intravenous administration of drugs in serum to kill the cells that make up your disease. If you do not have
chemotherapy, your disease will progress, and this can affect your life. With chemotherapy, your disease can
regress and be controlled; however your disease may continue to progress despite chemotherapy. Even if
chemotherapy responds, regresses, or even if there is no evidence of disease, your disease may recur after a while.
Chemotherapy is administered by trained nurses under the control of a medical oncologist.

Chemotherapy will be administered for a specific period of time planned for you. This period may vary depending on
your response or the tolerance to the treatment. The chemotherapy drugs
........................................................................................... planned for you shall apply for ................. days with daily
intervals of .............. This treatment planned for you shall continue minimum ............................. cure (................
months).

Chemotherapeutic drugs also affect normal cells as well as disease cells. Therefore, some side effects may occur
due to drugs. Chemotherapy drugs most commonly have side effects on bone marrow, hair and digestive tract cells.
By the effects of bone marrow, the production of normal blood cells may decrease, causing anemia, susceptibility to
infections, bleeding; can cause hair loss with the effects on hair cells; you may have mouth sores, nausea- vomiting
and diarrhea with the effects on the digestive system. In a few cases, it can have side effects to your organs such as
your heart, liver, kidneys, and lungs. The necessary medical precautions will be taken to minimize the side effects,
preliminary examinations will be carried out and the functions of these organs will be followed if necessary. The
degree of these incidents may vary depending on the patient and the drugs used. Allergy can develop if you have
hypersensitivity to the chemotherapy. There are following side effects of the above mentioned drugs that will be
applied to you except these general side effects of chemotherapy drugs:
...................................................................................................
...................................................................................................................................................................

The information about the side effects of the medications you will use and the precautions to be taken are given in
detail at the attachment.

I read and understand the above information. I declare that I learned the benefits, risks and complications of the
chemotherapy, I made an enlightening and satisfying conversation about the chemotherapy with Dr
._________________________ , I received clear answers to all my questions, I give full permission and
authorization to the team doctors with the free will in the applications of the medical oncology department doctors'
decisions which are appropriate and necessary for chemotherapy application.

Potential benefits and risks that may arise in case of rejection of process:………………………………
…………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………
Lifestyle recommendations that are critical to your health:………………………………………………………………………..
…………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………
If necessary, you can get medical help on the same topic from …………………………………………………………………
…………………………………………………………………………………………………………………………………………………
 REPUBLIC OF TURKEY
MINISTRY OF HEALTH
Health Sciences University Kartal Dr. Lütfi Kırdar Training and Research Hospital
INFORMED PATIENT CONSENT FORM FOR CHEMOTHERAPY
CODE DATE OF ISSUE REVISION NO DATE OF REVISION PAGE NUMBER/PAPAER COUNT
YN.RB. 311 15.08.2008 04 08.01.2018 2/2
Name-Surname of the
patient
Date of Birth

Identity Number

PLEASE FILL THE FOLLOWING FIELDS HANDLY.

IF THE PATIENT IS CONSCIOUS IF THE PATIENT IS UNCONSCIOUS

Please write in the below space the following expression: Please write in the below space the following expression:
*(I have read hereby informing and consent form/ my relative has *(I have read hereby informing and consent form/ my relative has
read to me and I have understood) and read to me and I have understood) and
*(I have received one copy by hand) *(I have received one copy by hand)

Patient’s
Legal Representative (Guardian) and/or Parent
Name&Surname
Name&Surname:
Phone Number.:..........................................................
Phone Number...............................
Signature:
Signature:

Doctor Doctor
Name Surname: Name Surname:
Signature: Signature:

Date/Hour of Receipt of the Consent: Date/Hour of Receipt of the Consent :

Note:
1- The patient is younger than 18 years old and his/her conscious is closed or he/she does not have signing authority, consent is
given by his/her representative.
2- Hereby form shall be filled in 2 copies and one copy shall remain in the patient.

SCOPE OF REVISION: The name of Hospital was revised as T.R. Ministry of Health Health Sciences
University Kartal Dr. Lütfi Kırdar Training and Research Hospital.
 REPUBLIC OF TURKEY
MINISTRY OF HEALTH
Health Sciences University Kartal Dr. Lütfi Kırdar Training and Research Hospital
INFORMED CONSENT FORM FOR THE BLOOD AND BLOOD COMPONENTS

CODE DATE OF ISSUE REVISION NO DATE OF REVISION PAGE NUMBER/PAPAER COUNT

YN.RB. 319 15.08.2008 06 08.01.2018 1/2
Name-Surname of the
patient
Date of Birth

Identity Number

□ I DON'T WANT TO BE INFORMED ABOUT THE SUBJECT

My doctor / the doctor of the patient ................................................. .. informed me that the

transfusion of the blood and blood components to me/my patient could make a significant
improvement or a positive change in the disease.

Blood and blood components can be following (additionally leucocyte-free, irradiated,

washed):
 Full blood,
 Erythrocyte suspension,
 Fresh frozen plasma,
 Thrombocyte suspension or cryoprecipitate.

Benefits and risks of this transplant procedure and alternative treatments were explained to
me. I learned that although blood and blood components are prepared and tested according to
legal and scientific rules, it may lead to various immunological, slergic, microbial, physical or
chemical transplant reactions unforeseen to me / my patient; although these reactions are
usually mild or moderate, it could be deadly, and this can happen even when my own blood is
given. I know that even if tested with the most current methods, it is rarely possible to transmit
certain viruses (including AIDS, hepatitis viruses, hepatitis B, hepatitis C, and possibly infection
after months or years) with the blood and blood component transfusion.
I had the opportunity to ask questions about transfusion of blood and blood components.
This “Informed Consent” I gave is valid until I discharge from the hospital.

Estimated time of the process:

Potential benefits and risks that may arise in case of rejection of process:……………………………………
……………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………
Lifestyle recommendations that are critical to your health:………………………………………………………….
……………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………
If necessary, you can get medical help on the same topic from …………………………………………………….
……………………………………………………………………………………………………………………………………
 REPUBLIC OF TURKEY
MINISTRY OF HEALTH
Health Sciences University Kartal Dr. Lütfi Kırdar Training and Research Hospital
INFORMED CONSENT FORM FOR THE BLOOD AND BLOOD COMPONENTS

CODE DATE OF ISSUE REVISION NO DATE OF REVISION PAGE NUMBER/PAPAER COUNT

YN.RB. 319 15.08.2008 06 08.01.2018 2/2
Name-Surname of the
patient
Date of Birth

Identity Number

PLEASE FILL THE FOLLOWING FIELDS HANDLY.

IF THE PATIENT IS CONSCIOUS IF THE PATIENT IS UNCONSCIOUS

Please write in the below space the following expression: Please write in the below space the following expression:
*(I have read hereby informing and consent form/ my relative has *(I have read hereby informing and consent form/ my relative has
read to me and I have understood) and read to me and I have understood) and
*(I have received one copy by hand) *(I have received one copy by hand)

Patient’s
Legal Representative (Guardian) and/or Parent
Name&Surname
Name&Surname:
Phone Number.:..........................................................
Phone Number...............................
Signature:
Signature:

Doctor Doctor
Name Surname: Name Surname:
Signature: Signature:

Date/Hour of Receipt of the Consent: Date/Hour of Receipt of the Consent :

Note:
1- The patient is younger than 18 years old and his/her conscious is closed or he/she does not have signing authority, consent is
given by his/her representative.
2- Hereby form shall be filled in 2 copies and one copy shall remain in the patient.

SCOPE OF REVISION: The name of Hospital was revised as T.R. Ministry of Health Health Sciences
University Kartal Dr. Lütfi Kırdar Training and Research Hospital.
 REPUBLIC OF TURKEY
MINISTRY OF HEALTH
Health Sciences University Kartal Dr. Lütfi Kırdar Training and Research Hospital
PATIENT INFORMATION AND CONSENT FORM
CODE DATE OF ISSUE REVISION NO DATE OF REVISION PAGE NUMBER/PAPAER COUNT
YN.RB.320 15.08.2008 07 08.01.2018 1/3
Name-Surname of the
patient
Date of Birth

Identity Number

DEAR PATIENT AND PATIENT’S RELATIVE, PLEASE READ THIS DOCUMENT CAREFULLY,
It’s your god-given right to have information about the processes / treatments offered to you for defining and
curing and identifying your disease and medical condition. The aim of this statement is to inform you on your
health and to associate you to this process self consciously. It is your choice whether you confirm the actions
which shall be taken after you learn the advantages and the risks of medical treatment.
If you do not know how to read write we can offer you or you can find a person who can provide
communication. You can allow someone you choose as a witness of meeting for permitting the process of
treatment and definition of disease.
You have the right to withdraw your permission anytime you want. This situation is not going to delay your
remaining treatment process. However, the right mentioned above depends on the condition that it shall not
have a medical incovenient feature. When this situation actualises, “Treatment/Medical Workup Rejection
Form” shall be prepared and annexed to the end of this document.
If you desire, all the information and the documents about your health shall be delivered to you or a relative
of yours.
NOTIFICATION
1. You have been hospitalized to the ……………………….. clinic of UNIVERSITY OF HEALTH
SCIENCES KARTAL DR LÜTFİ KIRDAR TRAINING AND RESEARCH HOSPITAL with the pre-
diagnosis of ……………………………………………. . Your disease is
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
……………………………………… .
The success of therapy for your disaese is % ……………………………………………………… .
2. Physical examination, injection of medicine, drawing blood, anatomic region of catheterization,
nasogastric catheter, urinary catheter, and injection processes and implementations which shall be
required fort he treatment and diagnosis for the disaese may be performed.
3. For the first application, different diagnosis definitions can be determined by doctors and other
medical practitioners in addition to the planned treatment and diagnosis implementations about your
health situation. Apart from pre planned diagnosis and treatment implementations, different actions
and processes can be performed by different clinics and disciplines.
4. Medical workup can be performed with medical devices like x-ray, fluoroscopy, ultrasonography,
scintigraphy, computed tomography, magnetic resonance etc. when required during the diagnosis
and treatment implementation.
5. We want you to know that; the diagnosis and treatment implementations which shall be performed
may not diagnose all the pathologies / diseases about your health, we can not give you the gurantee
of full recovery for all kinds of the diaseases still you have or you have not still noticed or pathological
situations/patients’s situation; also, there can be disease/pathological situations and complications
depend on the results of the diagnosis and treatment of the disease and we can see new
disease/pathological situations and complications which can ocur during or after the implementations.
THE RISKS WHICH CAN OCCUR WHEN YOU REJECT THE TREATMENT
1.
2.
ALTERNATIVE TREATMENT METHODS
1.
2.
NOTES RELATED TO THE PATIENT
CONSENT
1. I know the meaning of the detailed consent form.
2. I have been hospitalized to ………………………………….. clinic with the with the pre-diagnosis of
……………………………………………. . Dr. ………………………………. has infromed me about the
processes of physical examination, injection of medicine, drawing blood, anatomic region of
catheterization, nasogastric catheter, urinary catheter, and injection processes.
3. I have been informed on the fact that for the first application, different diagnosis definitions can be
determined by doctors and other medical practitioners in addition to the planned treatment and
diagnosis implementations about your health situation. Apart from pre planned diagnosis and
treatment implementations, different actions and processes can be performed by different clinics and
disciplines.
4. I have been informed on the fact that Medical workup can be performed with medical devices like x-
ray, fluoroscopy, ultrasonography, scintigraphy, computed tomography, magnetic resonance,
mammography etc. when required during the diagnosis and treatment implementation.
5. I have been informed on the fact that the diagnosis and treatment implementations which shall be
performed may not diagnose all the pathologies / diseases about your health, we can not give you the
gurantee of full recovery for all kinds of the diaseases still you have or you have not still noticed or
pathological situations/patients’s situation; also, there can be disease/pathological situations and
complications depend on the results of the diagnosis and treatment of the disease and there can be
new disease/pathological situations and complications which can occur during or after the
implementations.
6. I have been informed about the risks and disadvantages that can ocur during the treatment.
7. I have been informed about the fact that I have the right to withdraw my permission anytime I want.
This situation is not going to delay myr remaining treatment process. However, the right mentioned
above depends on the condition that it shall not have a medical incovenient feature. Also I have ben
informed about the fact that when this situation actualises, “Treatment/Medical Workup Rejection
Form” shall be prepared and annexed to the end of this document.
8. I have been informed about the fact that there can be other health risks when i deny the diagnosis
and treatment methods offered to me and whether there is another treatment method which shall be
implemented instead of the method mentioned above.
9. I have been informed about the costs which are estimated for the diagnosis and treatment methods
which shall be implemented in the hospital because of my disease.
10. I have red all of this document clearly / this document has been red to me because of the reason that
i do not know how to read/ this document has been translated to me. I have understood all the written
sentences above. I had the opportunity to ask, evaluate and decide concerning my health situation
during and after my application and while filling this form.
11. I believe that I had enough and satisfactory information about the implementations of diagnosis and
treatment and my health situation after I have red this document and had answers to my questions,
and I provide the confirmation by signing this form with my freewill and with no pressure.

Verbal notifications has been made.

Important Properties of Medicines Used::
……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
Potential benefits and risks that may arise in case of rejection of process:………………………………………………………..
………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………
Lifestyle recommendations that are critical to your health:………………………………………………………………………..
………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………….
If necessary, you can get medical help on the same topic from ……………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………
The people to whom the patient gave authorization / Relatives who examines theprocess (himself/herself, wife-husband,
child,other)::…………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
PLEASE FILL THE FOLLOWING FIELDS HANDLY.

IF THE PATIENT IS CONSCIOUS IF THE PATIENT IS UNCONSCIOUS

Please write in the below space the following expression: Please write in the below space the following expression:
*(I have read hereby informing and consent form/ my relative has *(I have read hereby informing and consent form/ my relative has
read to me and I have understood) and read to me and I have understood) and
*(I have received one copy by hand) *(I have received one copy by hand)

Patient’s
Legal Representative (Guardian) and/or Parent
Name&Surname
Name&Surname:
Phone Number.:..........................................................
Phone Number...............................
Signature:
Signature:

Doctor Doctor
Name Surname: Name Surname:
Signature: Signature:

Date/Hour of Receipt of the Consent: Date/Hour of Receipt of the Consent :

Note:
1- The patient is younger than 18 years old and his/her conscious is closed or he/she does not have signing authority, consent is
given by his/her representative.
2- Hereby form shall be filled in 2 copies and one copy shall remain in the patient.

SCOPE OF REVISION: The name of Hospital was revised as T.R. Ministry of Health Health Sciences University Kartal Dr.
Lütfi Kırdar Training and Research Hospital.
 REPUBLIC OF TURKEY
MINISTRY OF HEALTH
Health Sciences University Kartal Dr. Lütfi Kırdar Training and Research Hospital
INFORMED CONSENT FORM FOR WOUND AND BURN TREATMENT CENTER GRAFT
OPERATION

CODE DATE OF ISSUE REVISION NO DATE OF REVISION PAGE NUMBER/PAPAER COUNT

YN.RB. 329 15.08.2008 04 08.01.2018 1/2
Name-Surname of the
patient
Date of Birth

Identity Number

DATE OF BURNS:
DATE OF SURGERY:

For the treatment of burn injuries in my body as a result of burning, my doctors recommend me to take skin
graft (Patch) with dermotom device from other areas of intact skin of my body and apply surgery for injured parts.
It was explained to me that this operation may have consequences such as anesthesia risks, bad scar,
wound bruising, failure to complete closure of the wound, bad scar in the area taken, infection, wound opening. I
was mentioned the possibility of not fully opening (contracture) in joints attached to the skin patches placed on the
joints. It was also said that after this surgery, other surgeries might be needed. I was informed that after surgery,
the plaster splint could be applied to various regions of my body for a while. I was told that after surgery, I might
need physical treatment for a while.
As a result, I consider all of these risks and rely on my doctors; I accept the recommended Graft Patch
operation with my free will.

Note: If the patient is unconscious, mentally incompetent or if he or she is a child, the progress of treatment and
the risks may be explained to his/her relatives, guardians or parents and consent can be taken.

Potential benefits and risks that may arise in case of rejection of process:……………………………………..
Alternatives of the process, if any: ………………………………………………………………………………………
……………………………………………………………………………………………………………………………………
Estimated time of the process: ……………………………………………………………………………………………
……………………………………………………………………………………………………………………………………
Important Properties of Medicines Used: ……………………………………………………………………………….
……………………………………………………………………………………………………………………………………
Potential benefits and risks that may arise in case of rejection of process:……………………………………..
……………………………………………………………………………………………………………………………………
Lifestyle recommendations that are critical to your health:………………………………………………………
……………………………………………………………………………………………………………………………………
If necessary, you can get medical help on the same topic from ……………………………………………………
 REPUBLIC OF TURKEY
MINISTRY OF HEALTH
Health Sciences University Kartal Dr. Lütfi Kırdar Training and Research Hospital
INFORMED CONSENT FORM FOR WOUND AND BURN TREATMENT CENTER GRAFT
OPERATION

CODE DATE OF ISSUE REVISION NO DATE OF REVISION PAGE NUMBER/PAPAER COUNT

YN.RB. 329 15.08.2008 04 08.01.2018 2/2
Name-Surname of the
patient
Date of Birth

Identity Number

PLEASE FILL THE FOLLOWING FIELDS HANDLY.

IF THE PATIENT IS CONSCIOUS IF THE PATIENT IS UNCONSCIOUS

Please write in the below space the following expression: Please write in the below space the following expression:
*(I have read hereby informing and consent form/ my relative has read *(I have read hereby informing and consent form/ my relative has
to me and I have understood) and read to me and I have understood) and
*(I have received one copy by hand) *(I have received one copy by hand)

Patient’s
Legal Representative (Guardian) and/or Parent
Name&Surname
Name&Surname:
Phone Number.:..........................................................
Phone Number...............................
Signature:
Signature:

Doctor Doctor
Name Surname:
Name Surname:
Signature:
Signature:

Date/Hour of Receipt of the Consent: Date/Hour of Receipt of the Consent :

Note:

1- The patient is younger than 18 years old and his/her conscious is closed or he/she does not have signing authority, consent is
given by his/her representative.
2- Hereby form shall be filled in 2 copies and one copy shall remain in the patient.

SCOPE OF REVISION: The name of Hospital was revised as T.R. Ministry of Health Health Sciences
University Kartal Dr. Lütfi Kırdar Training and Research Hospital.
 REPUBLIC OF TURKEY
MINISTRY OF HEALTH
Health Sciences University Kartal Dr. Lütfi Kırdar Training and Research Hospital
ORGAN PLANTATION SURGERY CLINIC
INFORMED CONSENT FORM FOR DONOR NEPHRECTOMY

CODE DATE OF ISSUE REVISION NO DATE OF REVISION PAGE NUMBER/PAPAER COUNT

YN.RB.330 15.08.2008 04 08.01.2018 1/3
Name-Surname of the
patient
Date of Birth

Identity Number

This operation is performed under general anesthesia. The entire kidney is removed. The other kidneys will assume all functions of
the kidney removed. The operation is performed with a 15-20 cm incision in the side of the torso. At the beginning of the operation,
a catheter is inserted into the bladder and a drain is inserted into the operation area at the end.
B- ANESTHESIA
For information about anesthesia and the risks involved, see the "information about anesthesia" information pages. If you have any
concerns, you can talk to your anesthetist about the subject. If the information sheet is not given to you, please ask for one.
C- GENERAL RISKS OF A SURGERY
a- Small areas of the lungs may close, which may increase the risk of lung infection.
Antibiotic therapy and physiotherapy may be needed.
b- Coagulation in the legs (deep vein thrombosis) can cause pain and swelling.
Rarely, some of these clots may go off to the lungs and become fatal.
c- A heart attack may develop due to an increase in the caliber load.
d- There may be death due to process.
D- RISKS OF THIS SURGERY
There are some risks / complications that this surgery carries. Risks in surgery:
1. Depending on the position given to your body during the operation, there may be muscle aches after the operation.
2. Large kidney vessels may bleed. In this case, additional surgery and blood transfusion may be needed.
3. It may be required to remove a rib during surgery. In this case, complications or deadness may appear in that area. A chest tube
may need to be inserted for ensuring ventilation of the lungs.
4. There may be occult bleeding in the abdomen. In this case fluid treatment, blood transfusion or additional surgery may be
required.
5. There may be infection complications such as accumulation of pus in the abdomen. In this case, antibiotic treatment and / or
abscess may need to be evacuated by a catheter attached to the skin (percutaneously) or by additional surgical intervention.
6. Uncomfortable drainage of post-operative urine specimens, especially in male patients due to urinary incontinence. This
condition is usually temporary and the function of the urinary incontinence is normal.
7. A bowel injury may occur and may cause the bowel contents to leak. It additional surgical intervention may be required.
8. Post-operative bowel movements may slow down and stop. Bloating in the pubes and fluid and drug treatment or surgical
additional treatment may be required in this case, which may cause vomiting.
9. In some patients, wound healing may be abnormal, in which case the wound may become thicker, red or painful. Herniation may
occur due to weak fascia in the bruise or sutures.
10. Muscle weakness due to cutting the nerve at the surgical site may develop, it can create a similar image.
11. Particularly in the case of obese patients, partial or complete wound opening may develop.
12. Adhesions may develop between the intestines after the operation. In this complication that may develop in the short term or
long term, fluid and drug treatment or surgical treatment may be required.
13. Kidney failure may develop. You may need dialysis. What you need to know about your disease: Your renal function and
structure are normal, and a close relative who has renal insufficiency may kidney you for kidney transplantation serving here. What
to do if the attempt is not made? The patient with renal insufficiency may begin dialysis, if the patient already has a dialysis, the
dialysis continues. Complications of dialysis and renal failure may occur in the patient What kind of treatment / intervention should
be administered (should include information on alternative therapies):
General anesthesia is used. The entire or part of the kidney is removed. The other kidneys will assume all functions of the kidney
removed. The operation is performed with a 15-20 cm incision in the side of the torso. At the beginning of the operation, a catheter
is inserted into the bladder and a drain is inserted into the operation area at the end. Alternatively, this can be done
laparoscopically in selected cases.
The operation is performed in a port (often operated on kidney transporters), which is operated through 3 or 4 thin tubes placed in
the skin from the side of the throat and sometimes allows the passage of the hand through it. The kidney is removed with a small
incision from the lower abdomen. At the beginning of the operation, place a catheter on the waist and a drain on the operation area
at the end. The success rate of this treatment is the same as that of open surgery, and there are advantages such as shorter
hospital stay and recovery time, fewer pain complaints and smaller scars in cosmetics.

Side effects that may occur:

• Frequent side effects: Pain
• Side effects that can be seen rarely: Infection of the wound site, prolonged ileus (the intestines do not work temporarily)
• Very rare side effects: bleeding due to injury to surrounding veins, sutures, bowel, liver or spleen injury, blood contamination
(bacteremia and / or sepsis) The question of the type, duration, side effects, success rate and success of the patient,
- Operation is usually performed under general anesthesia as previously planned. in surgery the entire kidney is removed. The
other kidneys will assume all functions of the kidney removed. The operation is performed with a 15-20 cm incision in the side of
the torso. At the beginning of the operation a catheter is initially placed in the waist and a drain is placed in the operating area at
the end.
- There are some risks / complications that this surgery carries and they have been stated herein above.
 REPUBLIC OF TURKEY
MINISTRY OF HEALTH
Health Sciences University Kartal Dr. Lütfi Kırdar Training and Research Hospital
ORGAN PLANTATION SURGERY CLINIC
INFORMED CONSENT FORM FOR DONOR NEPHRECTOMY

CODE DATE OF ISSUE REVISION NO DATE OF REVISION PAGE NUMBER/PAPAER COUNT

YN.RB.330 15.08.2008 04 08.01.2018 2/3
Name-Surname of the
patient
Date of Birth

Identity Number

- What is meant by the success is the removal of the kidney from the body without developing any complications. The function of
the removed kidney is taken over by the other kidney after removal of the kidney.
Things the patient should look for before the intervention:
You will have surgery and you should not drink anything from day one. You should cut blood thinners such as aspirin, Coraspin
and its derivatives one week in advance. At night, you should clean the bowel as recommended by your doctor.
What the patient should look for after the intervention:
On the first day of surgery, you must walk unless you are told otherwise. After 1 week you should get your stitches removed. You
must observe medication and diet recommended for you and You should arrive at times recommended for your prescribed
medication and diuretic and regular check-ups.
Things that the doctor wants to know about the patient:
Drugs used:
Bleeding time:
Operations undergone:
Allergy:
Other diseases:
Physician’s notes on informative speech:
................................................................................................................................................................................

Estimated time of the process: ................................................................................................................................

Important Properties of Medicines Used: ...........................................................................................................................

................................................................................................................................................................................

Potential benefits and risks that may arise in case of rejection of process. .......................................................................
................................................................................................................................................................................
...............................................................................................................................................................................
Lifestyle recommendations that are critical to your health: ................................................................................................
If necessary, you can get medical help on the same topic from ...........................................................................................

Explanation of the consent of the patient, parent or guardian:

• My doctor gave me necessary explanations about my health condition.
• I learned more about what planned treatment / initiative is, the necessity, the course of the procedure and other treatment options,
their risks, the consequences of not being treated, the likelihood of treatment success and side effects.
• I understood what I should pay attention to before and after the treatment / intervention.
• During the diagnosis / treatment / intervention, all documents related to me and samples taken could be used for educational
purposes.
• My doctor responded in a way that I could understand all my questions.
• I have been informed about the people who will apply for treatment / intervention.
• I am in my head and I see myself competent enough to decide.
• I know that I don’t have to give consent to my treatment/initiation if I don’t want to and / or I know that I can stop the process in the
stage I want.
 REPUBLIC OF TURKEY
MINISTRY OF HEALTH
Health Sciences University Kartal Dr. Lütfi Kırdar Training and Research Hospital
ORGAN PLANTATION SURGERY CLINIC
INFORMED CONSENT FORM FOR DONOR NEPHRECTOMY

CODE DATE OF ISSUE REVISION NO DATE OF REVISION PAGE NUMBER/PAPAER COUNT

YN.RB.330 15.08.2008 04 08.01.2018 3/3
Name-Surname of the
patient
Date of Birth

Identity Number

PLEASE FILL THE FOLLOWING FIELDS HANDLY.

IF THE PATIENT IS CONSCIOUS IF THE PATIENT IS UNCONSCIOUS

Please write in the below space the following expression: Please write in the below space the following expression:
*(I have read hereby informing and consent form/ my relative has *(I have read hereby informing and consent form/ my relative has
read to me and I have understood) and read to me and I have understood) and
*(I have received one copy by hand) *(I have received one copy by hand)

Patient’s
Legal Representative (Guardian) and/or Parent
Name&Surname
Name&Surname:
Phone Number.:..........................................................
Phone Number...............................
Signature:
Signature:

Doctor Doctor
Name Surname: Name Surname:
Signature: Signature:

Date/Hour of Receipt of the Consent: Date/Hour of Receipt of the Consent :

Note:
1- The patient is younger than 18 years old and his/her conscious is closed or he/she does not have signing authority, consent is
given by his/her representative.
2- Hereby form shall be filled in 2 copies and one copy shall remain in the patient.

SCOPE OF REVISION: The name of Hospital was revised as T.R. Ministry of Health Health Sciences University Kartal Dr.
Lütfi Kırdar Training and Research Hospital.
 REPUBLIC OF TURKEY
MINISTRY OF HEALTH
Health Sciences University Kartal Dr. Lütfi Kırdar Training and Research Hospital
KIDNEY TRANSPLANT CONSENT FORM FOR INFORMED PATIENT

CODE DATE OF ISSUE REVISION NO DATE OF REVISION PAGE NUMBER/PAPAER COUNT

YN.RB.343 11.02.2015 03 08.01.2018 1/4
Name-Surname of the
patient
Date of Birth

Identity Number

Our dear Patient;

Regardless of the cause of kidney failure, there are three main treatment options for patients who have recently
reached final stage:
1.Continuous, regular hemodialysis,
2.Continuous peritoneal dialysis,
3.Renal transplantation from live or cadaver donors.
In dialysis treatments, only the filtering functions of the kidney are fulfilled, hormonal functions are missing. After
successful kidney transplant:
1. There is no need for dialysis treatments, the patient becomes independent,

2. Dietary and fluid restrictions are largely lifted from the center,
3. The individual feels better physically and psychologically, since all functions of a healthy kidney are
performed. The quality of life of patients is much better than dialysis.
Because of these advantages, kidney transplantation should be considered the best option for the treatment of
renal failure.
However, kidney transplant has also some risks and side effects; namely:
In order to prevent rejection of the transplanted kidney by the body, after the operation, two or three drug
treatment programs are applied throughout the life span.
These medications can often prevent renal rejection; however, it also reduces body resistance and causes two
major side effects:
1. The defense of the body against all kinds of microbial diseases is reduced,

2. The risk of tumor formation is slightly higher than in normal people .

Despite these risks, it is a preferred treatment because of its advantages.
GENERAL INFORMTION ABOUT KIDNEY TRANSPLANT:
The kidney is transplanted from live or cadaver donors. Kidneys taken from relatives with blood-ties between them are
usually more compatible with the patient's body. During surgeries performed on such live donors, the patient and
kidney donor are examined in detail, prepared, and transported when optimal conditions are met. For him, the chance
of success with live donors is more, the risk of surgery is less. However, the success of transplants made from
cadavers has also been increased by the fact that patients waiting for cadaveric kidneys are prepared in detail before
transfer and new drugs are introduced.
Kidney transplantation: The kidney transplanted during surgery is placed right on the left or on the left.
This kidney is a large artery located in the lower abdomen of the abdomen, and the vein is erected in a
large vein in this part of the abdomen. The urine tube is pierced. Under appropriate conditions, all this
surgery takes about 2-4 hours. There is also a risk of kidney transplant surgery, as each has its own risk.
But thanks to the new techniques that are developing, there is no risk to life. The duration of hospitalization
after surgery is 10-20 days on average, with everything normally developing and ongoing.
Blood group compatibility between kidney donor and patient:
 For renal transplantation, it is required that the recipient and donor be matched firstly by blood groups. Blood
groups are mainly divided into 0, A, B and AB. A group of 0 blood donors can donate everyone (0, A, B and AB).
A patient from the AB blood group can take organs from each donor. Individuals from groups A and B can give or
receive an organ suitable for their group. This situation is summarized in Table-1.
 REPUBLIC OF TURKEY
MINISTRY OF HEALTH
Health Sciences University Kartal Dr. Lütfi Kırdar Training and Research Hospital
KIDNEY TRANSPLANT CONSENT FORM FOR INFORMED PATIENT

CODE DATE OF ISSUE REVISION NO DATE OF REVISION PAGE NUMBER/PAPAER COUNT

YN.RB.343 11.02.2015 03 08.01.2018 2/4
Name-Surname of the
patient
Date of Birth

Identity Number

 Transfusions can also be performed between patients with uncomplicated blood groups; but in general, the risk of
rejection and other problems after these transfers is slightly higher. The Ministry of Health does not allow such
transfers.
Organ Buying of Organ Donation by Blood Groups
Blood Group from which To which Blood Group it
Blood Group
It can Receive Organ can Donor Organ
0 0 0, A, B, AB
A A, 0 A, AB
B B, 0 B, AB
AB 0, A, B, AB AB
Rh blood group type does not matter during organ transplantation.
Tissue groups consistency between renal donor and patient:
In kidney transplantation, it is useful to have a good match between tissues, other than blood group
compatibility. Tissue compliance tests investigate the similarity of the tissues and organs of the body of the patient
with the kidney donor to the transplant. The more similar the tissues of two individuals are, the less likely it is that the
transplanted organ will be rejected by the patient's body. Usually the textures of parents are partially compatible with
their children. Between siblings, full compliance or moderate compliance can be observed, and sometimes a complete
tissue mismatch can be seen. Tissue maturation research is done by taking blood from the recipient and donor .
Renal transplantation may be performed among non-tissue-compatible (unrelated) or distantly related
individuals, but the risk of rejection in these types of transplants is slightly greater in the future. Therefore, more
severe drug treatment may be required to prevent rejection, which may increase the disadvantages mentioned above.
Legally, it is necessary for ethics committees of the centers to receive approvals for such donors. The most
appropriate unrelated donors in ethical terms are spouses and distant or relatives (such as father-in-law mother-in-
law).
BASIC INFORMATION ABOUT KIDNEY TRANSPLANTATION
 There is no definite upper age limit for patients with kidney transplant. However, in patients older than 65 years,
post-operative problems are often frequent. For that reason, it is often more convenient for these patients to stay
in dialysis treatment. At this age, the disadvantage of kidney embryos may be greater than the advantage.
 Medications to prevent rejection of the implanted kidney after transplant will reduce your body resistance and
defenses. For this reason, if you have a recent infectious disease, this disease should be avoided until you are
fully recovered.
 The kidney transplant can be performed for people who have cancer. However, it is necessary to determine that
it has already been treated adequately and that it has not recurred for at least 1 year.
 In some diseases that lead to kidney failure, the same disease may recur in the transplanted kidney. However,
no kidney disease, including diabetes caused by diabetes, prevents organ transplantation. In some diseases the
transplant is delayed for a period of time.
 A recent heart attack or partial paralysis will also require postponement of the operation. After the disease has
been treated adequately, kidney transplantation is again on the agenda.
 B and C hepatitis patients can also be transplanted. However, for these patients a special investigation must be
done before the live transplant or waiting list is taken, and sometimes the treatment should be started.

SOME QUESTIONS AND ANSWERS ON KIDNEY TRANSPLANTATION

1. Is there a difference between the preparations of candidates for transplantation from live or cadaveric donors?
No. Candidates on the cadaveric kidney waiting list are examined just as candidates for live donation. However, as it
is unclear when a cadaveric kidney will be found, it may be necessary to repeat a preliminary examination and some
 REPUBLIC OF TURKEY
MINISTRY OF HEALTH
Health Sciences University Kartal Dr. Lütfi Kırdar Training and Research Hospital
KIDNEY TRANSPLANT CONSENT FORM FOR INFORMED PATIENT

CODE DATE OF ISSUE REVISION NO DATE OF REVISION PAGE NUMBER/PAPAER COUNT

YN.RB.343 11.02.2015 03 08.01.2018 3/4
Name-Surname of the
patient
Date of Birth

Identity Number

laboratory investigations over time. For this reason, patients on the cadaveric kidney waiting list are required to visit
the control at regular intervals. Briefly; Patients waiting for cadaveric kidneys should be ready at any moment .
2. Are candidates for transplant patients removed from their own kidneys?
Patients usually do not get their kidneys touched. However, if the persistent blood pressure is high, the kidneys are
resistant to treatment, the urine is overflowed from the abdomen, and the presence of very large cysts is present,
diseased kidneys are removed. This surgery is done before the transfer in some centers and after 3-4 weeks new
kidney is inserted. In some centers while kidney transplant surgery is performed, the patient's own kidneys are also
removed. However, it takes quite a long time for both surgeries to be done in the same session and it is a little more
risky.
3. How long is the waiting period for patients enrolled in the cadaver kidney list?
It is still not possible to specify a definite period in our country. A patient who is very new to the list may be able to get
a short-term transplantation chance with proper kidney removal, and sometimes can wait a long time because a
suitable kidney has not come out. As long as the possibilities are available, a longer waiting illness is given priority in
the appropriate kidney output.
As the organ donation increases in our country, it will shorten the waiting period on the cadaver kidney list.
4. What should we do for kidney transplantation?
If you have a living relative donor candidate, you should apply with your donor candidate to the organ donor
center that best suits your blood group as described above. If you do not have such a donor candidate, you
should apply to enter the waiting list of an organ transplant center that you will be able to access within 3-4
hours. You may only be on a waiting list for one center.

Estimated time of the process: …………………………………………………………………

Important Properties of Medicines Used: ……………………………………………………………………………………………….
………………………………………………………………………………………………………………………………………………………

Potential benefits and risks that may arise in case of rejection of process:………………………………………………………..
………………………………………………………………………………………………………………………………………………………
Lifestyle recommendations that are critical to your health:………………………………………………………………………..
………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………….
If necessary, you can get medical help on the same topic from ……………………………………………………………
 REPUBLIC OF TURKEY
MINISTRY OF HEALTH
Health Sciences University Kartal Dr. Lütfi Kırdar Training and Research Hospital
KIDNEY TRANSPLANT CONSENT FORM FOR INFORMED PATIENT

CODE DATE OF ISSUE REVISION NO DATE OF REVISION PAGE NUMBER/PAPAER COUNT

YN.RB.343 11.02.2015 03 08.01.2018 4/4
Name-Surname of the
patient
Date of Birth

Identity Number

PLEASE FILL THE FOLLOWING FIELDS HANDLY.

IF THE PATIENT IS CONSCIOUS IF THE PATIENT IS UNCONSCIOUS

Please write in the below space the following expression: Please write in the below space the following expression:
*(I have read hereby informing and consent form/ my relative has *(I have read hereby informing and consent form/ my relative has
read to me and I have understood) and read to me and I have understood) and
*(I have received one copy by hand) *(I have received one copy by hand)

Patient’s
Legal Representative (Guardian) and/or Parent
Name&Surname
Name&Surname:
Phone Number.:..........................................................
Phone Number...............................
Signature:
Signature:

Doctor Doctor
Name Surname: Name Surname:
Signature: Signature:

Date/Hour of Receipt of the Consent: Date/Hour of Receipt of the Consent :

Note:
1- The patient is younger than 18 years old and his/her conscious is closed or he/she does not have signing authority, consent is
given by his/her representative.
2- Hereby form shall be filled in 2 copies and one copy shall remain in the patient.

SCOPE OF REVISION: The name of Hospital was revised as T.R. Ministry of Health Health Sciences University Kartal
Dr. Lütfi Kırdar Training and Research Hospital.
 REPUBLIC OF TURKEY
MINISTRY OF HEALTH
Health Sciences University Kartal Dr. Lütfi Kırdar Training and Research Hospital
TIBIA FRACTURE AND CRURIS REGION OPERATION INFORMED CONSENT FORM

CODE PUBLICATION DATE REVISION NO REVISION DATE PAGE NO/PAGE NUMBER

YN.RB.360 07.04.2015 03 08.01.2018 1/3
Patient Name
Surname:
Birth Date:
TR ID No:
File No:
Date/Hour:

Orthopedics and Traumatology Clinic

Surgery risks
 There is a risk of hospital infection during the hospitalization period at the hospital. In this case, long-
term antibiotic therapy and physiotherapy may be required. Long-term job loss may occur.
 Heart attack episode may be due to pain, body fluids going out of the vein and shock.
 There may be a risk of death.
 There may be permanent leg pain and limping

The risks of surgical procedures:

 In the thigh region where it is applied with the effect of antibleeding bandage (tourniquet) used during
surgery, skin and intestine may become blackened, ie, tissue necrosis (death). Surgery such as
transplantation of the skin may be necessary for its treatment.
 Vein and nerve damage due to tourniquet may occur. As a result, there is a risk of loss of legs.
 Infection may occur at the site of the fracture. The resulting infection may require new surgery and
long-term antibiotic treatment. Despite the treatments, the limited movement of the knee at early
onset may occur because of a long time stay.
 Excessive pain may occur after surgery. The color changes and permanent complaints, such as
swelling at the leg may occur.
 Pain in the incision site applied for surgery and loss of sensation in a certain area may be permanent.
 Local infection, lung infection may occur in the operation area. They may require long-term antibiotic
treatment and long-term hospitalization. There is a risk that the resulting infection will not heal and
return to bone infection. In this case, many surgeries and long-term treatments may be needed. The
risk of losing the leg may occur. There may be long-suffering.
 Pre-operative, intra-operative and post-operative blood clotting in the vein and rupture of fat particles
may occur. This can cause the clot to break from its place and go to the lungs and the brain. Deaths
or paralysis without treatment may develop accordingly.
 Limitation of movement of the knee and ankle due to the lack performance of the exercises in the
postoperative period and weakening and melting in the muscles may occur. Long-term physical
therapy may be needed.
 Materials used during surgery may break during and after surgery. In this case, there may be a
second surgery. The material used in surgery can be broken despite low risk in the next period.
 Post-operative pain shock associated with excessive pain may occur.
 Failure to unify the fracture may occur. Different operations may be needed. An X-ray may be
required after the operation. The radiation to be received has a late carcinogenic effect. This may
increase the risk of cancer.
 The choice of surgical technique can be decided during surgery. For this reason, the form surgery can
be changed.
 Broken line can grow during surgery. Depending on this, the skin incision can be enlarged. For union
of fracture, the tissue can be taken from the hip or other corpse and placed in a broken line.
 The tissue on the fracture may die due to crushing. In this case, it is necessary to perform operations
that require skin transplantation.
 Excessive swelling in the pre- and post-operative period can cause tension in the tissue and death in
the tissues. This may require skin transplantation. It can cause leg loss.
 You may need to stay in bed for a long time. This may cause bed sores. They may require long-term
treatment and plastic surgery.
 Post-operative plaster may be required. Plaster casts can cause pressure on the skin under the
plaster, scar formation on the skin, and movement limitation in the joints. Tissue trapping can occur
with plaster cast. In this case removal of plaster, skin correction operations and doing plaster again
may be necessary.
Anesthesia: I know that anesthesia brings additional risks, but I want to use anesthesia to protect from pain
and for the planned procedure and additional procedures for recovery of the pain. I am aware of that the
method of anesthesia can be changed without knowledge of me.
 REPUBLIC OF TURKEY
MINISTRY OF HEALTH
Health Sciences University Kartal Dr. Lütfi Kırdar Training and Research Hospital
TIBIA FRACTURE AND CRURIS REGION OPERATION INFORMED CONSENT FORM

CODE PUBLICATION DATE REVISION NO REVISION DATE PAGE NO/PAGE NUMBER

YN.RB.360 07.04.2015 03 08.01.2018 2/3
Patient Name
Surname:
Birth Date:
TR ID No:
File No:
Date/Hour:

The consequences if treatment is not accepted: If no surgical procedure which is appropriate for me is
done, I have been told about the possible conditions of my disease.
PERMISSION OF THE PATIENT
I accept these below:
The doctor explained my medical condition and the procedures to be applied. I understand the risks of
procedure to be applied, the risks that may be specific to me, and the possible consequences.
The doctor explained the other treatment options and associated risks. The doctor also explained the risks
that could develop outside of the surgery.
The doctor explained the risks of anesthesia and the factors that increase the risk of anesthesia.
I asked my doctor about my condition, risks, treatment procedures to be applied, and concerns about
treatment options. My questions and concerns were discussed, answered, I am satisfied and convinced.
I allow the doctor to make documents such as all medical documentary documents to be made before, during
and after the surgery, as well as photographic video footage as required and to use them in the necessary
publications. I agree to stay in the hospital until the doctor allows me to discharge and I will adhere to the
hospital rules.

Potential benefits and risks that may arise in case of rejection of process:………………………………………………
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
Lifestyle recommendations that are critical to your health:………………………………………………………………………..
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
If necessary, you can get medical help on the same topic from …………………………………………………………
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
 REPUBLIC OF TURKEY
MINISTRY OF HEALTH
Health Sciences University Kartal Dr. Lütfi Kırdar Training and Research Hospital
TIBIA FRACTURE AND CRURIS REGION OPERATION INFORMED CONSENT FORM

CODE PUBLICATION DATE REVISION NO REVISION DATE PAGE NO/PAGE NUMBER

YN.RB.360 07.04.2015 03 08.01.2018 3/3
Patient Name
Surname:
Birth Date:
TR ID No:
File No:
Date/Hour:

PLEASE FILL THE FOLLOWING FIELDS HANDLY.

IF THE PATIENT IS CONSCIOUS IF THE PATIENT IS UNCONSCIOUS

Please write in the below space the following expression: Please write in the below space the following expression:
*(I have read hereby informing and consent form/ my relative has *(I have read hereby informing and consent form/ my relative has
read to me and I have understood) and read to me and I have understood) and
*(I have received one copy by hand) *(I have received one copy by hand)

Patient’s
Legal Representative (Guardian) and/or Parent
Name&Surname
Name&Surname:
Phone Number.:..........................................................
Phone Number...............................
Signature:
Signature:

Doctor Doctor
Name Surname: Name Surname:
Signature: Signature:

Date/Hour of Receipt of the Consent: Date/Hour of Receipt of the Consent :

Note:
1- The patient is younger than 18 years old and his/her conscious is closed or he/she does not have signing authority, consent is
given by his/her representative.
2- Hereby form shall be filled in 2 copies and one copy shall remain in the patient.