INFORMED CONSENT FOR SURGERY AND SPECIALS PROCEDURE

Patient’s Name:
File No.:
DOB:
Mobile Number:
Visit Date:
Registration Time:
Doctor Name:

I hereby authorize M.D or his/her designee to perform the following surgical operation/ special procedure:


The nature of surgical procedure / special procedures, its anticipated effects including significant risks, benefits, potential complications and alternatives available to me has been explained by M.D on and I understand and I’m satisfied with these explanations.

The treating physician or his/her designee are entitled to provide additional procedure as they deemed reasonable and beneficial to me and according to rules and regulations including administration of anesthesia which the physician deems necessary during the operation.

I do authorize the to use their discretion in disposal of my removed tissue or organ according to rules and regulations.

The anesthetist explained to the patient the nature and the risks involved in performing the anesthesia to the above described procedure and its likely outcome.

The surgeon will do his/her best to get better results but there is no guarantee about the result of the operation.

*** In case the patient’s condition or age reasonably precludes the ability to grant informed consent the above information has been explained to the following legal representative and treatment is hereby authorized.

I understand and agree that I am financially responsible for the payment I made for that any amount I paid for the sessions or procedures I booked it will only be valid up to 3 months from the date I made the payment. I understand that I need to utilize the sessions or procedures within 3 months period. I agree that my payment made is non-refundable or non-transferable post this period.

I declare that I have read and fully understood all points in this consent and that all of my questions were answered to my satisfaction and I take the full responsibility of my decision in this consent.

 

Patient Name & Signature :   

Doctor/Therapist Name & Signature :   

Witness Name & Signature :     

Parent or Gaurdian Name (if patient is minor) :

Date :

Consent to be photographed and published

I, , consent to be photographed and published on Social media, by while before and after the procedure. I further authorize that the photographs may be published for any purpose and in any form.

Patient Name & Signature :