RECEIPT

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OUTPATIENT CONSENT
UHID:
Date:
Permission is hereby granted to the doctor(s) and other professionals of NMH to provide
routine medical care for

...,
including assessment, pathological testing and rendering treatment on an out-patient
basis. I have been informed and understand that HIV (human immunodeficiency
virus)/AIDS, HCV (hepatitis C virus) and HbsAg (hepatitis B virus) tests may be performed
on me without my consent if a health professional, facility employee or First Responder
sustains an exposure to my blood or other body fluid. I shall follow the medical care
related instructions of the treating doctor and be honest with regard to my feedback in
subsequent visits.
I understand that medical science doesnt guarantee any treatment/ investigation.
I am here for the treatment out of my own will & own the responsibility of all the risks
involved in my treatment and hereby relieve the Doctors and staff of NMH from legal
obligations.
I understand that I am financially responsible for all of the charges and bills associated
with my care and treatment.
I shall give 24 hrs prior notice in the event that I need to reschedule my/ my patients
appointment. In case I do not, my appointment shall be cancelled and I shall make a new
appointment.
I shall abide by the rules and regulations of Hospital.
I acknowledge and understand that I am responsible for my personal valuables. I release
NMH from any liability for loss by theft or negligence of mine or any staff of my personal
valuables.

Patient/ Patients appropriate legal representatives

Name:
Signature: