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    Consent Form Surgery

    Uploaded by

    Gaurav Arora
    1. This document is an informed consent form for surgery, medical treatment, and anesthesia for a patient named _________________. 2. It authorizes Dr. _________________ and their team to perform the surgical procedure of __________________ on the patient and explains the risks involved. 3. It also authorizes the use of anesthesia and medications during surgery as deemed appropriate, and blood transfusion if needed.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Consent Form Surgery

    Uploaded by

    Gaurav Arora
    518 views2 pages
    1. This document is an informed consent form for surgery, medical treatment, and anesthesia for a patient named _________________. 2. It authorizes Dr. _________________ and their team to perform the surgical procedure of __________________ on the patient and explains the risks involved. 3. It also authorizes the use of anesthesia and medications during surgery as deemed appropriate, and blood transfusion if needed.

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    Consent form surgery

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    1. This document is an informed consent form for surgery, medical treatment, and anesthesia for a patient named _________________. 2. It authorizes Dr. _________________ and their team to perform the surgical procedure of __________________ on the patient and explains the risks involved. 3. It also authorizes the use of anesthesia and medications during surgery as deemed appropriate, and blood transfusion if needed.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    518 views2 pages

    Consent Form Surgery

    Uploaded by

    Gaurav Arora
    1. This document is an informed consent form for surgery, medical treatment, and anesthesia for a patient named _________________. 2. It authorizes Dr. _________________ and their team to perform the surgical procedure of __________________ on the patient and explains the risks involved. 3. It also authorizes the use of anesthesia and medications during surgery as deemed appropriate, and blood transfusion if needed.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    Hospital

    Informed Consent
    for Surgery,Medical treatment and anaesthesia

    Name of patient ______________________________ Age ______ Sex ___

    Father’s / Husband’s name _______________________________________

    Complete postal address _________________________________________

    Telephone nos. ________________________________________________

    1. We [patient and the patient party and relatives] have come to Sen Nursing
    Home on our own will. We are fully aware that all the relevant facilities for
    the treatment are available over here.
    2. By signing on this informed consent form we hereby authorize Dr.
    _____________________________ and his team to operate upon Mr. /Mrs.
    ___________________________________________________
    the following surgical procedure
    ________________________________
    ________________________________________________________.
    I / we have been explained the name of the surgery, why it is being done and
    what is the indication of the surgery, the amount of the risk involved in it,
    the possibility of deterioration of the condition of the patient have been
    explained to me/ us which we fully understand and are ready to go ahead
    with it.
    3. I hereby authorize the doctor and his team to use any appropriate
    technique of anesthesia as they deem proper in my case.
    4. I hereby authorize the doctor to use the medications during the surgery,
    transfuse blood [if need be].We fully understand that if at all the blood
    transfusion is required it is our duty and responsibility to arrange the blood.
    5. We have been fully given to understand that sometimes during the
    surgery, emergency can arise because of which extra surgery and medical
    treatment which is more and besides the planned surgery has to be carried out.
    In certain cases of laparoscopic surgery at times open surgery has to be carried
    out in view of unforeseen surgical circumstances. In such an eventuality the
    expenditure also goes beyond the planned expenditures. I am ready for this
    extra risk and extra expenditure [if at all required]. In cases of laparoscopic
    surgery, for some reason it the hospital stay crosses two days, the expenditure
    goes beyond the planned expenditure for which I am / we are ready.
    6. I have been explained the high risk in my case because of following points
    ________________________________________________________
    ________________________________________________________
    ________________________________________________________
    ________________________________________________________
    ________________________________________________________.
    7. No promises have been made to me or any guarantees given to me by the
    doctors or the hospital.
    8. I hereby solemnly affirm that I / we have fully gone through this
    consent form, understood it in letter and spirit. Before I signed all the
    vacant spaces and non essential points have been cut.
    Signed after reading

    Patient’s signature _________________________________

    Patient’s thumb impression

    Father’s/ Husband’s signature ________________________

    Doctor’s signature _________________________________

    In case patient is a minor or mentally compromised, guardian’s signature

    __________________________________________________

    Witness ____________________Date and time.

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