INFORMED CONSENT DURING COVID-19
(Should be translated in local language)
Facility: Covid /Non Covid -ward COVID Status: Positive/ Negative/ Unknown
Place of Consent: Triage area/ at admission/ Casualty
Contact history with confirmed case of COVID: Positive/ Negative
Travel history to affected area: suggestive/non-suggestive
History of Fever/ Cough/ Respiratory symptoms: Yes/ No
Resident of containment zone: Yes/ No
I, __________________ F/M/H/S/D/o, _____________________ (Patient Name) Age _____ Address
______________________ having Hospital No/ Aaadhar no _________________________understand that
I am admitted for an COVID-19 treatment at the Health care facility and I knowingly and willingly consent
to adhere the following Policies and Protocols of the Health Care facility during the COVID-19 pandemic.
1) I understand that COVID-19 is extremely contagious and is believed to spread by person-to-person
contact. I will consent to having my temperature taken by any representative of the Holy Cross
Hospital authorities, provide any follow up information, wear a mask at all times while at Hospital
premises and will adhere to the protocols/ norms specified by the hospital authorities from time to
time to prevent the spread of COVID-19.
2) I understand that no Attenders/ Bystander will be allowed to visit the patient/ no separate
accommodation will be provided to the Attenders.
3) I understand the tariff of COVID-19 treatment to patient only on Daily Package basis. I hereby agree
to pay Rs. ………………… daily for my/ my patient’s treatment.
4) I also understand that any treatment/investigation/ procedure done to me/ my patient with respect to
his/her pre-existing medical conditions may not be included in the above package.
5) I hereby acknowledge and assume the risk of COVID-19 treatment, and I give my express
permission for the treating doctor Dr ……………………………and concerned staffs to proceed
with the same.
6) I acknowledge and accept that this declaration shall be deemed to be my consent for Holy Cross
Hospital to store, record, report this declaration with the Government or health authorities as may be
necessary to prevent the further spread of the COVID-19. And I hereby consent to Holy Cross
Hospital sharing my health data with the government and the health authorities.
7) I understand that During the course of the treatment, to protect the healthcare personnel and the
patient from further exposure to COVID 19, consumables used during the course of the treatment
shall be charged to the patient.
8) I have been counseled adequately by Dr and staffs in the language that I/my
patient can understand.
9) I will not hold the doctor, the hospital or its staffs morally or legally accountable for any reason.
This is to state that I _______________________ have comprehensively explained the information
above along with the explanation provided by the doctor to the patient and/or her attendant have
informed me that they have understood the information completely.
Signature of Patient Signature of Legally acceptable authorizer (LAR)/Witness
Name of the patient: Name of the LAR/Witness:
Address:
Contact No:
Date and Time:
Signature of Doctor:
Name & Designation:
Address:
Contact no:
Date and Time
INFORMED CONSENT DURING COVID PANDEMIC
It has been explained to me in a language I understand that patient ................................................
…………. years of age, Hospital ID No / Aadhar No: ........................................ with the diagnosis
of......................................... has been admitted under Dr............................................................ for
emergency/elective surgery ............................................ during the COVID 19 pandemic. In this time, every
hospital is considered a high risk zone for transmission of Corona SARS virus. Therefore, any surgical
procedure carries additional risk, as the patient, patient party, hospital staff or the treating doctor may be an
asymptomatic carrier or an unsuspected COVID patient and there is a chance of the surgical patient
contracting the Illness In the post- operative period. That may entail prolonged hospitalisation, ICU transfer
and care and a 20% increased risk to life in these circumstances. At the present time, there is /there is no
provision for COVID testing in this hospital.
I have agreed to treatment in this hospital, after having understood these facts. I also give an undertaking
that I/my patient .................................................... does not have any signs and symptoms of the SARS
COVID Infection (fever, cough, difficulty in breathing, loss of taste sensation and /or loss of smell) at
present. I hereby understand that the doctor will take all possible precautions to prevent such an infection
from happening. I promise to follow all protocols prescribed for the safety of the patient by him/her. I have
also been counseled regarding the additional cost of protective equipment required. I hereby authorise
Dr............................., and her/his team to operate on the patient. In event of the patient or party contracting
the Corona SARS Virus infection, even after all protocols are followed, I will not hold the doctor, the
hospital or its staff morally or legally accountable for the same.
This is to state that I .............................................. , have comprehensively explained the information above
along with the discussion/explanations provide by the doctors, to the patient and/or his/her attendant in a
way which I believe he/she/they can understand and the patient and/or his/her attendant have informed me
that they have understood the foresaid information completely.
Signature of the patient Signature of Witness/ Interpreter
Name: Name:
I, __________________ F/M/H/S/D/o, _____________________ (Patient Name) knowingly and willingly consent to
adhere the following Policies and Protocols of the Health Care facility during the COVID-19 pandemic.
1. I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show
symptoms and still be highly contagious. It is impossible to determine who has it and who does not, given the
current limits in virus testing.
2. If I am an asymptomatic carrier or an undiagnosed patient with COVID 19, I suspect it may endanger doctors and
clinic staff. It is my responsibility to take appropriate precautions and to follow the protocols prescribed by them.
3. I am aware that I may get an infection from the clinic or from a doctor, and I will take every precaution to prevent
this from happening, but I will not at all hold doctors and clinic staff accountable if such infection occurs to me or my
accompanying persons.
4. In case I or my attendant get the COVID 19 infection after the visit to the clinic, I will inform the clinic authorities at
the earliest, so that appropriate tracking of the patients/attendants and clinic staff present on the day of my visit can
be done.
5. I confirm that I am not presenting any of the following symptoms of COVOID-19 listed below: a - Fever b -
Shortness of Breath c - Loss of Sense of Taste or Smell d - Dry Cough e - Runny Nose f - Sore Throat Initials-
__________________
6. I understand the government recommends social distancing of at least 6 feet for a period of 14 days to anyone
who has shown symptoms or tested positive.
7. I verify that I have not travelled outside of India in the past 14 days to countries that have been affected by COVID-
19.
8. I verify that I have not travelled domestic within India by commercial airline, bus, or train within the past 14 days.
9. I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to
treatment completed during the COVID-19 pandemic. If I hide my facts and relevant details and because of my
knowing or unknowing behaviour or action the clinic staff gets infected, I may be held responsible for appropriate
compensation in the court of law.
Name:____________________________________ Sign/Thumb impression: _______________________
Date:____________________
