Consent For Surgical/invasive Procedure Form printable pdf download

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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.

(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:

________________________________

__________________________________

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)

Consent For Surgical/invasive Procedure Form

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