Patient Consent Form

I ..................................... son/daughter of ............................... aged ................ resident of ........................................... being under the treatment of ....................................... (state here name of doctor/hospital/nursing home) do hereby give consent to the performance of medical /surgical /anesthesia/ diagnostic procedure of ....................................................... (mention nature of procedure / treatment to be performed, etc.) upon myself/upon ................................................... aged ............. who is related to me as ................................... (mention here relationship, e.g. son, daughter, father, mother, wife, etc.).

I declare that I am more than 18 years of age. I have been informed that there are inherent risks involved in the treatment / procedure. I have signed this consent voluntarily out of my free will without any pressure and in my full senses.

Place : __________________

Date : __________________

Signature ( To be signed by parent /guardian in case of minor): __________________

Time : __________________

NOTES :-

• This Consent Form should be signed BEFORE the treatment is started. These formats may be modified as per individual requirements.
• These formats should be in local language and in certain cases it would be prudent to have a proper witness to the consent signature.
• Informed consent forms for various situations can be made for Nursing Homes / Hospitals. Help of lawyers may have to be taken. Detailed forms on medical history can also be maintained. Keep all records safely in order.
• It is important to note that written consent should refer to one specific procedure. Obtaining a ‘blanket’ consent on admission does not have legal validity.