CONSENT FOR SURGICAL OPERATION / PROCEDURE / TREATMENT
Name :
Age :
File No. :
Attending Staff :
CONSENT FOR SURGICAL OPERATION / PROCEDURE / TREATMENT
Date
I, Mr.,Miss,Mrs
Age
AS Patient myself
Representative of patient (Mr./Mrs./Miss)
Age
Being the aforementioned patient's
hereby gives consent
and willingness to
, member of the Medical Council and holder of a
medical profession's license no.
to perform the anesthesia
Examination and/ or treatment procedure and/ or operation of
Using anesthesia which the doctor deems appropriate for the medical condition and/ or disease,
disability
Using a contrast media intravenously for Radiological study
Others
I acknowledge that the doctor has explained my medical condition(s) and the purposed procedure is to determine the definite causes in order to have a
proper therapeutic plan and treatment.
I also understand that complications may occur with any operation/ procedure such as the Potential for infection, blood clots in veins and lungs,
hemorrhage, allergic reactions.
Indication :
Risk related to the procedure :
Alternative procedures :
It has been explained to me that I may need a blood and blood components transfusion to promote recovery, stabilize my condition or save my life.
My doctor will decide the amount and type of blood and blood components transfusion which based on my particular needs.
Benefits/ risks/ alternatives of blood and blood components transfusion and the consequences of refusal that include seriously
jeopardizing my health or resulting in death have been explained to me.
I hereby agree for HIV serology test as the routine pre-operative or delivery screening.
Name :
Age :
File No. :
Attending Staff :
I hereby agree for infectious disease screening (including HIV Serology) if a staff member is injured while exposed to my body fluids.
I have received and do fully understand the Patient’s Right Declaration.
I have therefore placed my signature below to enable the medical team to provide the care and treatment.
()
()
Signature of the patient/ guardian/ relative
Signature of the witness
()
()
Signature of doctor
Signature of the witness
Advance directive :
No
Yes, please specify name
Relationship
Tel. No.
Interpreter’s Statement
An interpreter service is required
No
Yes
For interpreter: I have given a sigh translation in
(the patient’s language) and assisted in
the provision of any verbal and written information given to the patient/ parent or guardian/ substitute decision-maker by the doctor.
