Hopital Name:
Doctor-in-charge / Principal Surgeon / Principal Interventionist:
Dr.     
Qualification: 
Address:       
Phone:          
Email:           
High Risk Consent Form
(This consent must be taken - in case of serious / complicated / risky / new - surgeries / procedures; for removing any organ; in high risk patients; for proceeding with a surgery / procedure in spite of any abnormal parameters of the patient. This list is indicative not exhaustive and in case of a dilemma it is always advisable to take this high-risk consent and not a general consent.)

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. Anticipated alternatives / additional - treatment / intervention / procedure / surgery that may have to be performed or attempted during the course of the proposed treatment / intervention / procedure / surgery: 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.
The anticipated alternatives / additional - treatment / intervention / procedure / surgery includes but may not be limited to:

4. Alternatives to the proposed treatment / intervention / procedure / surgery:
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.

The alternatives that have been explained to me includes but are not limited to:  

5. Material risk/s of the proposed treatment / intervention / procedure / surgery:
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.
The material risks that have been explained to me includes but are not limited to:

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.
I had specifically raised the following questions and the same were suitably answered:  
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 explained and have understood that the proposed treatment / procedure / surgery is uncommon / complicated / risky.
10. I have been explained and have understood that the proposed treatment / procedure / surgery is based on technique / procedure / drug / protocol that is relatively new.
11. I have been explained and have understood that the proposed treatment / procedure / surgery has high rate of failure.
12. I have been explained and have understood that the proposed treatment / procedure / surgery has high rate of relapse and recurrence.
13. I have been explained and have understood that the proposed treatment / procedure / surgery generally require multiple sessions / sittings and I give my consent for the same.
14. I have been explained and have understood that the proposed procedure / surgery generally require second intervention and I give my consent for the same.
15. I have been explained and have understood that the proposed procedure / surgery generally requires further corrective surgery / procedure to deal with known post-procedure / surgery complication/s and I give my consent for the same.
16. I have been explained and have understood that the proposed procedure / surgery generally requires ‘re-exploration’ and I give my consent for the same.
17. Multi-stage treatment
I have been explained and have understood that the proposed treatment / procedure / surgery is a multi-stage treatment / procedure / surgery and I do hereby consent for each and every stage of the same.
The different stages of the proposed treatment / procedure / surgery that have been explained to me include but are not limited to:
18. I have been explained and have understood that I may need long-term treatment.
19. I have been explained and have understood that I may need long-term follow-up care.
20. I have been explained and have understood that I may need longer period for recovery.
21. Patient’s refusal of the first / best option and choice of another option that is also medically acceptable.I say that I was given the following options:
22. Patient’s Representative/s
I say that if I am incapacitated to communicate in future, further directions should be taken from the following person/s:
Name:
Address:
Mobile:

Name:
Address:
Mobile:

Name:
Address:
Mobile:
23. I have been advised of the option to take a second opinion from another doctor regarding the proposed treatment / procedure / surgery.
24. I state that after explaining, counseling and disclosures I had been given enough time to take decision for giving consent.
25. 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: