CONSENT TO TELEVISING OPERATION OR TREATMENT
In the interest of medical education and knowledge, I, __________________________ (name of patient), consent to the televising of the ______________________________ (operation or other treatment or procedure, as the case may be) that is scheduled to be performed on me on or about ____________________ (month & day), _________ (year). I authorize Dr. ________________ and _______________________________ (name of hospital) to admit to the operating room all necessary personnel who are to participate in the televising of this operation, in addition to the necessary doctors and staff.
________________________________ (Signature)
__________________ (Date)
________________________________ (Witness)
__________________ (Date)