CONSENT WAIVER OF MEDICAL / SURGERY

I who signed under this :

Name : ...........
Age : . years old
Gender : Male / Female
Address : ...........
Phone : ...........
Relation to the patient : ...........

Patient's name : ...........

Age : . years old
Gender : Male / Female
Address : ...........
Phone : ...........
Treated at : Room... Class
Medical record number :
Pre-operation diagnose : ...........

Hereby agrees to be taken medical / surgery :

. Of the patient with / without general anesthesia / local.
I make this statement with the fact that :
1. Explanation has been given by the doctor about the patient's disease, treatment options,
and medical action / treatment as well as the dangers, risks, and possibilities for action
arising from the medical, and fully understood the explanation given by the doctor.
(...................... / initials )

2. I also agreed to do further medical treatment, if necessary for the patient's safety.
(. / initials)

Type of medical treatment / surgery : ..

Type of examination patologi anatomy :

Cibinong, .
Doctor who explain That makes the statement

_________________________ _________________________
Clear name Clear name

Ist Witnness (from hospital) 2nd Witnness (from family)

_________________________ _________________________
Clear name Clear name