Hopital Name:
Doctor-in-charge / Principal Surgeon / Principal Interventionist:
Dr.
Qualification:
Address:
Phone:
Email:

 Consent Form
 
Information about the patient:
Name: Mr./Ms./Mrs.
Age: Years
Address:

Information about the patient’s guardian (proxy consent) :
(This clause should be filled and the guardian should sign this consent only in case of incompetent patients i.e. minors, old aged, unconscious, mentally unfit, disoriented patients)
Name: Mr./Ms./Mrs.
Address:
Phone no.
Relationship with the patient, if any:
[A person accompanying an unrelated patient should write ‘Unrelated-accompanying’ and when consent is given by higher authorities of a hospital, designation such as ‘Medical Superintendent’ or ‘Medical Director’ must be written.]

Scheduled date for the proposed intervention / procedure / surgery:

Doctor-in-charge / Principal Surgeon / Principal Interventionist:
Name:
Qualification:

Name/s of the proposed treatment / intervention / procedure / surgery:
a.
b.
c.
d.
I, the undersigned, do hereby state and confirm as follows:
1. I have been explained the following in terms and language that I understand. I have been explained the following in ……. (name of the language or dialect) that is spoken and understood by me.
2. I have been explained; I have been provided with the requisite information; I have understood; and thereafter I consent, authorize and direct the above named doctor-in-charge / principal surgeon / principal interventionist and his / her team with associates or assistants of his / her choice to perform the proposed treatment / intervention / procedure / surgery mentioned hereinabove.
3. I have been explained and have understood that due to unforeseen circumstances during the course of the proposed treatment / intervention / procedure / surgery something more or different than what has been originally planned and for which I am giving this consent may have to be performed or attempted. In all such eventualities, I authorize and give my consent to the medical / surgical team to perform such other and further acts that they may deem fit and proper using their professional judgment.
4. I have been explained and have understood the alternative methods and therapies of the proposed treatment / intervention / procedure / surgery, their respective benefits, material risks and disadvantages.  
5. I have been explained and have understood that the proposed treatment / intervention / procedure / surgery has certain material risks / complications and I have been provided with the requisite information about the same. I have also been explained and have understood that there are other undefined, unanticipated, unexplainable risks / complications that may occur during or after the proposed treatment / intervention / procedure / surgery.  
6. I state that the doctor-in-charge / principal surgeon / principal interventionist has answered all my questions to my satisfaction regarding the proposed treatment / intervention / procedure / surgery.  
7. I have been explained and have understood that despite the best efforts there can be no assurance about the result of the proposed treatment / intervention / procedure / surgery. I further state and confirm that I have not been given any guarantee or warranty about the results of the proposed treatment / intervention / procedure / surgery.  
8. I have been explained and have understood that despite all precautions complications may occur that may even result in death or serious disability.  
9. I have been advised of the option to take a second opinion from another doctor regarding the proposed treatment / procedure / surgery.  
10. I state that after explaining, counseling and disclosures I had been given enough time to take decision for giving consent.  
11. I have signed this consent voluntarily out of my free will and without any kind of pressure or coercion.  

Date & Time of giving consent:
Patient’s / Guardian’s Signature / Thumb impression:
Patient’s / Guardian’s Name:

Witnesses:
(Not compulsory. This part should be filled only in high risk cases; or when the patient / patient’s guardian is illiterate or not conversant with English; or when the patient has been unable to personally sign this consent for any reason.)
We confirm that the aforesaid has been explained to the patient / patient’s guardian in the terms and language that the patient / patient’s guardian understand in our presence. We further confirm that the patient / patient’s guardian has put his / her signature / thumb impression on this consent in our presence.
Witnesses No. 1’s Signature:
Witnesses No. 1’s Name:

Witnesses No. 2’s Signature:
Witnesses No. 2’s Name:

Doctor-in-charge / Principal Surgeon / Principal Interventionist’s Signature: