TITLE OF SURGERY

Name of Patient : ...........................................................................................................

Sex : ............... Age: ..................... Registration no: ...................................
Address : ...........................................................................................................
.............................................................................................................
Diagnosis : ...........................................................................................................
Operation Title :............................................................................................................

I ......................................................................................... the undersigned give consent for MY

OWN/ AFOREMENTIONED PATIENT’S operation and/or medication / investigation / anaesthesia
/ therapy / procedure etc.

The following procedure will be performed:

The expected outcome and likelihood of success is: Good / Fair / Poor

Risks of the procedure:

There are risks and complications with this procedure. They include but are not limited to the
following.

 Bleeding can occur which may require blood transfusion or further surgery or laparotomy.

 Infection or septicemia can occur, requiring antibiotics and further treatment.



 Allergic reaction can occur from medicines or by blood transfusion.
 Small areas of the lung can collapse, increasing the risk of chest infection. This may need
antibiotics and physiotherapy.
• Heart attack or stroke could occur due to the strain on the heart.
• Blood clot in the leg (DVT) causing pain and swelling. In rare cases part of the clot may
break off and go to the lungs and produce damage to organ
• Loss of function of any limb or organ or paralysis/paraplegia/quadriplegia.
• Cardiac arrest & Death as a result of this procedure is possible.

Specific Risks: (If any; for this particular patient due to _____________________________):
_____________________________________________________________________________
* Alternatives to the procedure suggested and supporting information regarding alternatives
_____________________________________________________________________________
_____________________________________________________________________________
* The ill effects of no treatment / procedure including the effect on the prognosis and the material
risks associated with no treatment ________________________________________________
_____________________________________________________________________________
* Instruction concerning what should be done if the procedure turns out to be harmful or
unsuccessful have been explained to me.

I acknowledge that the doctor has explained;

 My medical condition and the proposed procedure, including additional treatment if the
doctor finds something unexpected. I understand the risks, including the risks that are
specific to me.
 The anaesthetic required for this procedure. I understand the risks, including the risks that
are specific to me.
 Other relevant procedure/ treatment options and their associated risks.
• My prognosis and the risks of not having the procedure.
• The procedure may include a blood transfusion.
• Tissues and blood may be removed and could be used for diagnosis or management of
my condition, stored and disposed of sensitively by the hospital.
• I have been explained that excessive bleeding, infection, cardiac arrest, pulmonary
embolism and complications like this can arise suddenly and unexpectedly while
undergoing medication / investigation / operation / therapy / procedure or anaesthesia.
• I give consent for any change in the anaesthesia or operative procedure as well as for
removal of any organ as deemed necessary by the doctors to immediately save my life in
case of emergency while undergoing medication / investigation / operation / therapy /
procedure.
• I have been made aware that after the above operation / medication / investigation / therapy
/ procedure and anaesthesia, instead of desired benefit, some complication may arise, I
request Dr. (Surgeon) ........................................................................................... and/or
Dr. (Anaesthetist) .................................................................................... to take decisions
in best interest of my health including calling any other doctors or shifting me to higher
centres.
 I was able to ask questions and raise concerns with the doctor about my condition, the
proposed procedure and its risks and my treatment options. My questions and concerns
have been discussed and answered to my satisfaction.
• I understand I have the right to change my mind at any time, including after I have signed
this form but, preferably following a discussion with my doctor.
• I understand that image/s or video footage may be recorded as a part of and during my
procedure.
• I accept that medicine is not an exact science and understand that no guarantees can be
given to the results and understand these limitations.

I have read the above writing / The above writing has been read out to me and is explained to me
in the .................................. Language by ............................... (Interpreter) which I understand.

I have understood the aforesaid and I am giving my consent willingly with sound mental state
without any Coercion, Undue influence, Fraud, Misrepresentation or Mistake of facts.
The copy of this consent was offered to me.
I request Dr. ................................................................. to perform upon me the above-mentioned
procedure.
Doctor
Sign.: .......................................................
Name: .....................................................
Address: .................................................
................................................................
Date ............................. Age...................
Time .......................................................
Witness
Sign: ......................................................
Name: ....................................................
Relation with Patient..............................
Address: ................................................
...............................................................
Date ............................. Age..................
Time ......................................................
Patient / Guardian
Sign/ Lt. Thumb Impression ...........................
Name: ..........................................................
Address: .......................................................
......................................................................
Date ............................. Age.........................
Time .............................................................
Witness
Sign: .............................................................
Name: ..........................................................
Relation with Patient.....................................
Address: .......................................................
......................................................................
Date ............................. Age.........................
Time .............................................................