Consent For Surgical/invasive Procedure Form

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院 院 院 院
Name ___________________________________
CANOSSA HOSPITAL (CARITAS)
Age ________________ Sex ________________
Consent for Surgical/Invasive Procedure
Ward / Bed No. _____ Hospital No. __________
(A)
I, _________________________ (Patient’s name), hereby voluntarily give my consent to
undergo the procedure of ____________________________________________________,
to be performed by Dr. ___________________________________________________
under General/ Local/ Regional Anaesthesia/ MAC/ IV Sedation/ no Anaesthesia.
OR
(B)
I, ____________________, the father/mother/guardian of ____________________
(Patient’s name), hereby voluntarily give my consent for the Patient to undergo the
procedure of _____________________________________________________________,
to be performed by Dr.__________________________________________________,
under General/ Local/ Regional Anaesthesia/ MAC/ IV Sedation/ no Anaesthesia.
___________________________________
____________________________________
Patient/Parent/Guardian’s name in block letter
Witness name in block letter
______________________________________
________________________________________
Patient/Parent/Guardian’s signature
Witness’s signature
ID/Passport No:
_______________________
Date:
Date:
________________________________
__________________________________
DOCTOR’S DECLARATION: I have explained the nature, risks and benefits of the operation to
the Patient/Parent/Guardian and have answered the Patient/Parent/Guardian’s questions. To the
best of my knowledge, the Patient/Parent/Guardian has been adequately informed and has
consented, and the details as such had been documented in the Patient’s Clinical Record.
___________________________________
_____________________________________
Doctor’s name in block letter
Doctor’s signature
Date: ______________________________
I, _______________________________ (Interpreter’ name), certify that I have truly, distinctly and
audibly interpreted the contents of this document into_____________________________ (insert
language or dialect) to the Patient/Parent/Guardian.
___________________________________
Date: ______________________________
Interpreter’s Signature
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03//2013 v2 (13B)

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