DEPARTMENT OF EMERGENCY MEDICINE

CONSENT FORM FOR MEDICAL TREATMENT

Name of the patient:

Age /sex: I.P No:
Date:

I the undersigned ------------------------------or we the attendants of

Mr./Mrs./Master./Miss----------------------------------- have been explained by the
team of doctors regarding the relevant medical diagnosis, treatment options
and serious condition of the patient.

I /we have been explained about the risks, prognosis and including the
risk of death due to the clinical condition of patient

I/we have had an opportunity to discuss and clarify any concerns with
team of treating doctors in this hospital. I /we agree that I/we understand the
results & outcome of treatment / procedure cannot be guaranteed.

I/we confirm that the risks & benefits of the medical treatment
explained to me and that my questions have been answered to my full
satisfaction and understanding.

Date: Signature of the patient/Attendant

Time: Name:
Witness: Relationship with the patient: