Informed Consent Form -DHA
INFORMATION SHEET
Patient Name :
Age/Sex :
DOB :
DoctorName:
Date:
Procedure Name:
DescriptionoftheProcedureandProcess
Explained in detail about the procedure to the patient/ Guardian about theprocedureandwhatwillhappenonastep-by-stepbasis.
Side Effects
Possible side effects which may occur were explained to the patient/Guardian and what will happen in the event of a side effect or an unexpected event.
Risks
Patients were given a detailed description of possible or anticipated risks and explained about the level of care that will be available in the event that harm does occur, who will provide it, and who will pay for it.
Complications
Usually, the Treatment is safe but still explained about any possible complications that could be caused as a result of the treatment.
Discomforts
Explained about the type and source of any anticipated discomforts that are in addition to the side effects and risks discussed above.
Benefits
Patient was well and clearly informed about the actual benefits of the treatment.
Confidentiality
Patient was explained that how the clinical team will maintain the confidentiality of data, especially with respect to the information about the patient including photography and videography except in case of emergency.
Right to Refuse treatment/procedure
As a patient/Guardian, I am aware that I have the right to refuse the treatment.
Alternatives to clinical procedure or treatment
Explained the established standard treatments for the patient’s condition which is available safely.
Financial Implications
Patient was informed about all the procedures/treatments provided that are not covered by insurance or which may require the full payment or co-payment.
PART II: CERTIFICATE OF CONSENT
Patient Consent Statement
I have read the foregoing information, or it has been read to me. I have had the opportunity to ask questions about it, and any questions that I have asked have been answered to my satisfaction. I consent voluntarily to undergo this treatment and understand that I have the right to withdraw from the procedure or treatment at any time without in any way affecting my medical care.
Name of Patient: Signature of Patient: 
Date:
Witness Statement
I have accurately read or witnessed the accurate reading of the consent form to the potential patient, and the individual has had the opportunity to ask questions. I confirm that the individual has given consent freely.
Name of Witness: Signature of Witness: Date:
HealthcareProfessionalDeclaration:
I have adequately explained to the patient about the procedure along with risks,adverse effects and the standard alternatives that are available for the procedure.I have permitted time and opportunity for the patient to ask questions and all questions have been answered to my knowledge.
Name of healthcare professional:
Signature of healthcare professional: Date: