CONSENT FORM

Patient Name: MR.NO:

AGE: SEX: DATE: TIME:

I, S/D/W OF: hereby authorize

Dr. Of the Hospital and /or members who form part of his/her team to
perform upon me/my patient the following operation or procedure.

DR. And/or members of his/her team have discussed with me in details,(a) the
nature, purpose, as well as the benefits of the proposed procedure and the risks involved.(b) The potential
risks of not carrying out the procedure; and(c) the likelihood of success and(d) possible alternative
treatment modalities and the risks involved.

Medical history:
Diabetes: Hypertension: Renal Disease

ASTHMA: ALLERGY: PREVIOUS DRUG REACTION:

CARDIAC DISEASE: PREVIOUS HISTORY OF REACTION:
PREGNACY: LMP DATE:

INVESTIGATION: SERUM UREA: SERUM CREATININE:

BLOOD PRESSURE: LATEST ULTRASOUND REPORT:

Signature of the patient or of the person consenting on behalf of patient

Designation: Relationship to the patient, if applicable

Date: time: DATE: TIME:

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