Consent For Surgical/invasive Procedure Form (Page 2 of 2) in pdf

(1) The proposed Procedure, includes the following:

(a)

Indication for performing the Procedure.

(b)

General nature of the Procedure.

(c)

Potential general risks of complications and side effects, including but not limited to

bleeding; wound infection; chest infection; other infection; heart attack; stroke;

blood clot in the leg veins; blood clot travelling to the lungs; and death.

(d)

Potential specific risks of complications and side effects relevant to the Procedure

and the Patient’s condition.

(e)

Other treatment options, and consequences of no treatment.

(f)

Additional and/or consequential treatment(s) or management which may become

necessary during or after the Procedure including:

intensive care; blood and or blood product transfusion; conversion to open

procedure from minimal invasive procedure; _______________________________.

(2) I understand that

(i)

by necessity, Medical Practitioners other than the Doctor may assist in performing

the Procedure;

(ii)

if tissues or organs are removed during the Procedure, they may be submitted for

pathological examination following which they will be disposed of appropriately, or

they may be disposed of without such pathological examination;

(iii)

during the Procedure, photographs or other recording may be taken which may be

used for medical documentation or teaching purposes. For the latter, the Patient’s

identity will not be disclosed or identifiable; and

(iv)

there is no guarantee that the Patient’s condition or prognosis will improve

following the Procedure.

(3) I confirm that I have been provided with an Information Leaflet on the Procedure (

copy

given) , and that I have reviewed the same, and that I fully understand the contents.

_____________________________________________________________________________

EXPLANATORY NOTES

The consent form should be signed by the patient if he/she is an adult and is in a fit state to do

so. Should the patient be unfit for this purpose, the form has to be signed by his/her

parent/relative/guardian.

If the patient is a minor, it is acceptable for him/her to sign if he/she is fully able to understand

the content of the consent form. Otherwise the parent/relative/guardian should sign. In

appropriate cases, both the minor patient and the parent/relative/guardian may sign the form.

The consent form should be signed by the Doctor who gave the explanation to the patient or

the Doctor who is to perform the operation.

4. The witness may be a member of the hospital staff or any appropriate third party.

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03//2013 v2 (13B)

Consent For Surgical/invasive Procedure Form Page 2

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