Scribd
Upload
40 views1 page

Patient Consent Form

This document is a patient consent form for hair transplant surgery, confirming the patient's voluntary agreement and understanding of the procedure, risks, and post-operative care. It includes sections for patient and witness signatures, as well as acknowledgment from the treating surgeon. The patient affirms they are over 18 and consent to the use of clinical photographs for publications.

Uploaded by

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

Patient Consent Form

This document is a patient consent form for hair transplant surgery, confirming the patient's voluntary agreement and understanding of the procedure, risks, and post-operative care. It includes sections for patient and witness signatures, as well as acknowledgment from the treating surgeon. The patient affirms they are over 18 and consent to the use of clinical photographs for publications.

Uploaded by

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

DATE:

PATIENT CONSENT FORM

I, ____________________________________________________ aged ___________ years


exercising my free will/choice, without any duress/pressure/ lure of incentive in any form,
hereby give my consent for hair transplant surgery. I hereby confirm that I am over 18 years
of my age. My pre-operative work up has been done willingly. I have been suitably informed
to me to my satisfaction, by the doctor; steps of procedure, possible complications of
surgery, post-operative care, follow up period and time period for results. I agree to
cooperate fully with the supervising doctor and to immediately inform if I suffer any unusual
symptoms. I will follow directions of doctors in-charge for post-operative care and follow up
period. I give my permission for taking clinical photographs and their use, if required, for
publications. No other compensation, in any form, called by any name, will be available to
me/my legal heirs. Knowing all above, I hereby record my consent for my elective hair
restoration surgery.

Signature of the patient with date:

Name: _______________________________

The patient was explained content of this form and then signed before me.

Signature of impartial witness with date:

Name: ________________________________

I confirm that I have explained the nature, purpose and possible complications of the

surgery to ______________________________

Signature with Date:

Name of the treating surgeon: ________________________

You might also like