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Informed consent
INFORMED CONSENT

Performing doctor
Information provider
Information receiver
1 Diagnosis (Working Diagnosis &
Differential Diagnosis)
2 Reasons diagnosis
3 Medical treatment
4 Indication
5 Procedure
6 Purpose
7 Risk
8 Complication
9 Prognosis
10 Alternative and risk

hereby declare that I have explained the above matter correctly, doctor signature
honestly and provided an opportunity to ask questions and/or discuss
Hereby declare that I have received the information as above which I pasient/guardian
marked in the right column, and have understood it signature
Informed Consent document Name :
Date of birth :
Medical record number :

Medical Action Approval

I am who signed below,
name
date of birth/age…….. Male/Female
address………….
I hereby express my consent to take medical action ……………………..
on (date)…………….. to me/to my…………………… named………………….., date of
birth/age……….male/female, address…………………..
I also realize that doctors will make efforts and because medical science is not an exact science,
the success of medical procedures is not a necessity, but very much depends on the permission of
the almighty God.

……………….. date ………………….. time …………….

person who stated doctor witness 1 (family) witness 2 (staff)

Refusal of Medical Action

I am who signed below,
name
date of birth/age…….. Male/Female
address………….
I hereby express my refusal to take medical action ……………………..
on (date)…………….. to me/to my…………………… named………………….., date of
birth/age……….male/female, address…………………..
I understand the need for and benefits of the medical action as explained above to me including
the risks and complications that may arise if the medical action is not carried out.

……………….. date ………………….. time …………….

person who stated doctor witness 1 (family) witness 2 (staff)