Generic Consent Form For Medical Surgery / Procedure / Investigation

GENERIC CONSENT FORM FOR MEDICAL SURGERY / PROCEDURE / INVESTIGATION

If you are human, leave this field blank.

Name of guardian *

Relationship *

Father

Mother

Relatives

Other (Please specified)Other (Please specified)

Identification No. *

Issue Place *

State/Province

Issue Date *

Expiration Date *

Current Address *

Country

Passport/Valid ID picture *

Maximum upload size: 67.11MB

I have received the detailed information from the physician concerning the proposed surgery , procedure , medication administration and/or investigations involved along with the following:

Patient's condition

Procedure's name

Length Of Operation

Type of anesthesia

Localized anesthesia

Regional anesthesia / Deep Sedation

Moderate Sedation

Success rate of the surgery or procedure

Risks and complications from refusal of surgery or procedure

Risks and complications from surgery or procedure

Expected outcome

Alternative treatment

As the patient's condition reasonably precludes the granting informed consent, The above information has been explained to the responsible guardians/relatives. The cost and treatment is hereby authorized.

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