GENERAL CONSENT FORM
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PATIENT’S NAME
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UID
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Gender
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Age
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S.
N
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DESCRIPTION
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1.
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I
………………………………………………………………………………..(name of patient), desire to avail medical
services at this facility and give my agreement to accept their services
related to diagnosis and care of my medical condition..
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2.
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- I understand
that this consent is a general consent and it includes routine
procedures and treatments such as physical examination, drawing blood
for lab tests, medication administration, taking X-rays, ECG, use of local anaesthesia and conduct
any non-invasive procedure etc.
- I also
understand that in case high risk or invasive procedure is required to
be done, whether for investigation or treatment, I will be asked for a separate
informed consent
- I acknowledge that
results of treatment in this hospital is not guaranteed and I cannot
hold hospital, its doctor or any other staff liable for an outcome,
unless and until I believe it to be because of negligence
- I also authorise
the hospital to collect and maintain a record of my basic information
and medical information. I understand that these information is
confidential and will be shared only with healthcare providers and used
only for my treatment purpose. Disclosure of my information to others
will done only after my authorization. (Except if the information is asked
by legal authorities)
- I assume full responsibility of my
personal belongings and valuables and hospital will not be responsible
for loss of any personal item
- I undertake that
I will abide by the rules and by-laws of the hospital
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3.
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I
understand that my consent will hold good till I get discharged or I decide
to revoke the consent and stop receiving the services of this hospital.
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Signature and
name of the person giving consent
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Date / Time
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Relationship
with the patient
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Signature and
name of the witness
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Date / Time
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Signature and name of the doctor
taking consent
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Date / Time
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