MODEL FORM OF INFORMED CONSENT

MODEL FORM OF INFORMED CONSENT

I ..................................... son of ............................... aged ................ resident of ........................................... being under the treatment of ....................................... (state here name of doctor/hospital/nursing home) do hereby give consent to the performance of medical /surgical /anesthesia/ diagnostic procedure of ....................................................... (mention nature of procedure / treatment to be performed, etc.) upon myself/upon ................................................... aged ............. who is related to me as ................................... (mention here relationship, e.g. son, daughter, father, mother,wife, etc.).

I declare that I am more than 18 years of age.I have been informed that there are inherent risks involved in the treatment / procedure. I have signed this consent voluntarily out of my free will without any pressure and in my fell senses.

Place :

Date : SIGNATURE

Time : ( To be signed by parent /guardian in case of minor)

NOTES :

1. This Consent Form should be signed BEFORE the treatment is started. These formats may be modified as per individual requirements or experiences of Hospitals /Nursing Homes.

2. These formats should be in local language and in certain cases it would be prudent to record a proper witness to signature consent.

3. Informed consent forms for various situations can be made for Nursing Homes / Hospitals. Help of lamay have to be taken. Detailed forms on Medical history can also be maintained. Keep all records in order and safely.

4. It is important to note that written consent should refer to one specific procedure. Obtaining a ‘blanket’ consent on admission does not have legal validity.