Surgery Consent Old

A2vIAha (1) Pe 1lo
Patient's Name . . t. . YB . 1
.. CR No. ********* * p***** *** Page No. 1
CONSENT FOR ANAESTHESi& SURGERY

1.
************* *********aa**
Thereby authorize Dr. Ram Manohar Lohia Hospital and those the hospital may
perform upon .... * ....the following medical treatment, surgical operation
designate
as staft or
andlor
diagnostic therapeutic procedures. a***
2.
It has been explained to me that

during the course of the operation/procedure, unforeseen conditions
may be revealed or encountered which necessitate
to or different from those surgical or other emergency procedures in addition
the above designated staff to
contemplated at the time of initial diagnosis. therefore, further authorize
perform such additional surgical or other procedures as they deem
necessary or desirable.
3.
I consent to the administration of anaesthesia and to use such

anaesthetics as may be deemed necessary
or desirable, except to the following exceptions...
******************************.*******************************
(Indicate exception or 'None').
.
***************************************rveaanwasdneae*******a**n*** ***** 0
Istate that I am not suffering from Hypertension/Diabetes/Bleeding Disorders/Heart Disease o r . . .

********srursooe*sossasuseoppeop****tnoon
************* *********
5.
Ialso state that I am not suffering from any known allergies or drug reactions.
6.
Ifurther consent to the administration of such drugs, infusions, plasma or blood transfusions or any
other treatment or procedures deemed necessary.
7.
The nature and the purpose of the operation

alternative methods, treatment, prognosis, and/or procedures, the necessity thereof, the possible
the
the investigative procedures/investigations risks involved and the possibility of complications
and treatment of my in
explained to me and I understand the same. condition/diagnosis have been fully
3.
ait facnou feaT raTI

Ihave been given an opportunity
to ask all/any questions and I have also been
any second opinion. given option to ask for
(2)
been made to me concerning the result of any

9. and promises has
that no guarantee
I acknowledge
procedure/treatment.
10.
or procedures to be performed including

or televising of the operations
I consent to the photographing educational purposes, provided my identity
for medical, scientific or
appropriate portions of my body, them.
or by descriptive tests accompanying
is not revealed by the pictures
11.
consent to the admittance of observers
For the purposes of advancing medical education, hereby give
I
to the operating room.
12
lalso give consent to the disposal by hospital authorities of any tissues or parts, wiich may be remeved
during the course of operative procedure/treatment.
13
l also give specific consent as specified below:
ICERTIFY THAT THESTATEMENTS MADE IN THE ABOVE CONSENT LETTER HAVE BEEN READ OVER
AND EXPLAINED TO ME IN MY MOTHER TONGUE ANDIHAVE FULLY UNDERSTOOD THE IMPLICATIONS OF
THE ABOVE CONSENT AND FURTHER SUBMIT THAT THE STATEMENTS THEREIN REFERRED TO WERE FILLED
IN AND ANY INAPPLICABLE PARAGRAPHS STRICKEN OFF BEFORE 1SIGNED/PUT MY THUMB IMPRESSION.
i r gaTRIT/3IT 5I FITT/Signature/Thumb
impression of Patient
aT/Date MName
fari AT, UAT Ua TM2T/Signature, nanme & address of the witnesses:-
1. *** **9*****************°**°*°*******o9* ****** 2. ********* *********o***o
******* **°************ *
WHEN PATIENT IS AMINOR OR UNABLE TO AFFIX SIGNATURE DUE TO MENTAL OR

PHYSICAL DISABILITY
Signature/Thumb impression of Guardian/Natural Guardian

Name & Relationship with Patient
All entries must be followed by slgnature with date and name
of the
person making the entries.
(3)
Patient's Name . t. .
. CR No.
3
...
Page No. 3
Signature
******
Name
****
Address of witnesses
1.nnsrnue*****
2 .
************°°*********. * ****a*****************************°
******
ICONFIRM THAT HAVE

TOTHE PERSON WHOHAS SIGNED EXPLÀINED
THE ABOVE
THE NATURE
AND EFFECTS OF THE OPERATION/TREATMENT
CONSENT FORM.
Date
SIGNATURE OF DOCTOR IN CHARGE
NAME
DESIGNATION
Do. ******* ****.
Prem Po (4) F1 2(6)/FORM-2
DR. RAM
MANOHAR LOHIA HOSPITAL, NEW DELHI 'o
o oe
OPERATION NOTES
a5...
foT
3T MARITAL STATUS C.R. No.
AGE SEX
NAME
favm as
WARD BED OccUPATION RELIGION
DEPTT.
Pre-Operative Diagnosis
3rTT Te fægra
Post Operative Diagnosis
5T/Major
Operative Procedure Proposed eT/Minor
Operative Procedure Executed

Tafafaa HETY 1 HETe 2
Surgeon : Assistant 1 Assistant 2
T
Ansesthetic: Ansethetic: | Nurse
faesfa faarA faym YT 72 14T
Material forwarded to Pathology
Department for Examination
Skin Preparation
aritE/Date
f q Findings
Ha frar/Record of all
uifam si/Organs examined

T4 aT/Procedure includes
aIT/Incision
au/Ligatures
Trs faar TT TT/Specimen seen removed
3uaE1/Drainage
4 h/Spouge count
HaT/Closure
TaHRTA/Blood loss
3TrT Tl HHa/Operative time
(Reporter to sign. in full at the end of

Reports)
OIC, GIPRB. ND/24RMLH(20,000)V2020.

Surgery Consent Old

Uploaded by

Copyright:

Available Formats

Surgery Consent Old

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Surgery Consent Old

Uploaded by

Copyright:

Available Formats

A2vIAha (1) Pe 1lo

CONSENT FOR ANAESTHESi& SURGERY

It has been explained to me that

I consent to the administration of anaesthesia and to use such

Istate that I am not suffering from Hypertension/Diabetes/Bleeding Disorders/Heart Disease o r . . .

The nature and the purpose of the operation

ait facnou feaT raTI

been made to me concerning the result of any

or procedures to be performed including

fari AT, UAT Ua TM2T/Signature, nanme & address of the witnesses:-

1. *** **9*****************°**°*°*******o9* ****** 2. ********* *********o***o

WHEN PATIENT IS AMINOR OR UNABLE TO AFFIX SIGNATURE DUE TO MENTAL OR

Signature/Thumb impression of Guardian/Natural Guardian

ICONFIRM THAT HAVE

Prem Po (4) F1 2(6)/FORM-2

Operative Procedure Executed

uifam si/Organs examined

(Reporter to sign. in full at the end of

You might also like

1. * 9***************°°*°*******o9* ** 2. * ***o*o