Scribd
Upload
6K views1 page

Informed Consent for Surgery

This document is an informed consent form for surgery. It details that the patient, [name redacted], requires major surgery to address a condition diagnosed after tests and investigations. The form lists general risks of surgery like infection, allergic reaction, and death. It also notes there may be procedure-specific risks. The patient acknowledges being informed of the risks and complications. The patient provides consent for the listed doctors to perform the surgery and any additional necessary procedures. The patient and witness signatures confirm agreement to proceed with the surgery.

Uploaded by

Rajitha Burla
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
6K views1 page

Informed Consent for Surgery

This document is an informed consent form for surgery. It details that the patient, [name redacted], requires major surgery to address a condition diagnosed after tests and investigations. The form lists general risks of surgery like infection, allergic reaction, and death. It also notes there may be procedure-specific risks. The patient acknowledges being informed of the risks and complications. The patient provides consent for the listed doctors to perform the surgery and any additional necessary procedures. The patient and witness signatures confirm agreement to proceed with the surgery.

Uploaded by

Rajitha Burla
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

TY & QUALIT

FE Y
SA O

Name:

F
EN

CA
PATI

RE
T R A U M A . E M E R G E N C Y. C R I T I C A L C A R E
12-2-718, Khader Bagh Rd, Rethibowli, Toli Chowki, Sex: Age: D.O.B:
Hyderabad-08 (T.S) Phone: 23515100, 23517100 Fax: 23513100
www.premierhospital.in I Follow us on Ward: Bed:
INFORMED CONSENT FOR SURGERY UMR No.: IP No.:

Name of the Doctors :

I / My Patient was admitted into the

hospital on after necessary investigations and tests it has been determined that

I / My Patient has condition know as

and I am told that this condition calls for major surgery and would require

(Surgical Procedure)

I understand and accept that during the procedure there may be general risk of infection.
Allergic reaction, Disfiguring Scar, Severe loss of function of any limb or Organ, Paralysis,
Paraplegia or quadriplegia, Brain Damage, Cardiac arrest, or death. In addition to those general
risks there may be other possible risks involved in this procedure. This risk and / or complication
may include but not limited to such complication as:

The above stated circumstance may make it necessary to do an extension of the original or
another procedure.

BY SIGNING THIS FORM, I ACKNOWLEDGE THAT I HAVE READ OR HAS THIS FORM READ AND
EXPLAINED TO ME AND THAT I FULLY UNDERSTAND ITS CONTENTS.

I HAVE BEEN GIVEN AMPLE OPPORTUNITY TO ASK QUESTIONS, AND ANY QUESTIONS
I HAVE ASKED HAVE BEEN ANSWERED OR EXPLAINED IN A SATISFACTORY MANNER.

I REQUEST DR. AND HIS / HER ASSOCIATES / ASSISTANTS


TO PERFORM THOSE ADDITIONAL PROCEDURE THAT MAY JUDGE TO NECESSARY.

Doctor’s Sign.: Witness:

Patient’s Sign.: Relationship with the patient:

Date & Time:

You might also like