Generic Consent Form For Medical Surgery / Procedure / Investigation

Name of patient/ Name of guardian *

Authorize person for the patient, whose name is ... *

Relationship *

Identification No. (guardian) *

Issue Place (guardian) *

State/Province

Issue Date (guardian) *

Expiration Date (guardian) *

Current Address (guardian) *

Country

Passport/Valid ID picture (guardian) *

Maximum upload size: 268.44MB

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

Estimated cost of operation (THB) *

This estimated cost for suture procedure only not included medicines/vaccines, follow-up wound dressing and stitch-off.

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.

Signature (guardian) *

Clear

State why the patient is not able to given consent personally (or sign this form) *

Minor - any unmarried male or female whose age has not reached the age of consent (20 years old)

Physical / Mental dosorder

Other (Please specify)Other (Please specify)