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INFORMED CONSENT FORM – GENERAL
SURGERY
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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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WARD / BED NO.
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S. N.
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DESCRIPTION
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1.
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I
here by authorize Dr……………………………………………………………………………….. and those whom he may
designate as associated or assistants, to perform upon………………………………………. ………………………………..(Myself
or name of patients when the consent is being given by an authorized person),
the following……………………………………….. ………………………………………… (Name of operation /
procedure)
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2.
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It
has been explained to me that during the operation / treatment / procedure,
unforeseen condition may encountered which may necessitate surgical or other
procedure in addition to or different from those contemplated. I therefore
further authorized the above named doctor and his designate to perform such additional
surgical or other procedure as are deemed necessary by them.
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3.
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Following
has been fully explained to me and I have understood the same
1.
The nature and procedure of the operation and/ or
procedure.
2.
Expected outcome of this procedure / operation
3.
The possible alternative to his method of
treatment.
4.
The risk involved in the treatment and
5.
The kinds and possibilities of complications
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4.
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It
has been explained to me that risk of the operation / procedure in my case is
high/low (………. %) because of the following factors:
1.
……………………………………………………………………………………………………………
2.
……………………………………………………………………………………………………………
3.
……………………………………………………………………………………………………………
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5.
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Having understood all
of above, I am ready to take the high risk involved and give my consent for
conducting the mentioned procedure / operation upon me / my patient.
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6.
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The nature of
anaesthesia viz……………………………………….. (General / spinal / local / other), the
possible variation in it, if that may be necessitated at the time of
operation / procedure, and risk involved has been explained to me, and I
consent for the same.
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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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