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Travel Consent

The document is a travel consent form for a patient, explaining the patient's condition and the risks involved in traveling. Relatives acknowledge understanding these risks, including potential vehicle breakdowns and road accidents, and agree not to hold anyone responsible for any adverse outcomes. It includes spaces for signatures of the patient, relatives, and medical officials.

Uploaded by

Manglemba Moirangthem
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© © All Rights Reserved
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401 views1 page

Travel Consent

The document is a travel consent form for a patient, explaining the patient's condition and the risks involved in traveling. Relatives acknowledge understanding these risks, including potential vehicle breakdowns and road accidents, and agree not to hold anyone responsible for any adverse outcomes. It includes spaces for signatures of the patient, relatives, and medical officials.

Uploaded by

Manglemba Moirangthem
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
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TRAVEL CONSENT

Date : / leejerKe

Time : / JesU

We the relatives of the patient


Deecner jÀiCee®es veelesJeeF&keÀ
have been explained in our own language about the present condtion of the
patient and the nature of the disease he/she is suffering from.
Demetve Deecneuee jÀiCee®es Deepeej Je meO³ee®eer HeefjefmLeleer ³ee®eer HetCe& keÀuHevee Deece®³ee Yee<esle keÀjÀve efoueer iesueer Deens.
We have been explained the risks involved in patient travelling
Deecneuee jÀiCee®³ee ³ee$esle ³esCeeN³ee Oeeske̳ee®eer HetCe& keÀuHevee Deens.
risks - D delay due to vehicle breakdown Road Accident
OeeskeÀe ë Jeenve KejeyeercegUs GMeerrj DeHeIeele
to

for
We understood these risks and hereby declare that in case of any untoward
consequences arising from travelling. We won’t hold responsible.

Signature of the Patient / Relatives:


mener jÀiCe / veelesJeeF&keÀeb®eer mener
Name: jÀiCee®es veeJe
Relation with Patient :
jÀiCeeMeer veeles
Resident Medical Officer’s Signature :
Name Resident Medical Officer : Dr.

Authorised by :

Head of Medical Administration

Uneventful eventful *
* In case of an event, do fill Incidence reporting form IHRC / EIWD/ 029

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