Form Number: CLS F0002 Version No: 01 A ND LIVER INSTITUTE AND RSEARCH CENTER Issue date: 13-12-2017 Department Name: Clinical Services Form Name: Informed Consent for Surgical & Invasive Procedures Thereby give my consent and authorize PKLI & RC. Dr. , his or her assistants and oth necessary, to perform the following operation ot other procedure: Tacknowledge that: 1. Dr explained to me the nature and purpose of the operation described above, including the risks and possible problems related to the surgery & the recovery, including the risk of bleeding, infection, cardiac arrest, setious injury, or death, and the possibilty of ether complications, have been explained to me by the above mertioned dacton ‘The possible alternatives to this treatment, including no treatment at all, have been explained to me. All my questions, ifany, have been answered to my satisfaction. Iam aware that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantee has been made as to the results that may be obtained. 2. I consent to the performance of the above-described operation or other procedure. If, during the operation or other procedure, other conditions are discovered that, in the best judgment of the medical staff of PKLI&RC Hospital, require an extension, alteration, or abandonment of the original ena or procedure, or a different operation or procedure, I authorize and request that it proceed. 35 1, authorize PKLI&RC to go for photography/ videography for my disease processes, 4, Exceptions to my consent, if any, are: 5. [also declare that the treating doctor had explained to me in detail about any possible complications or side effects internationally recognized such 6. I verify the information above was given & appears to have been understood. Patient / legal representatives name Signature with date and time Relationship to patient Witness name Signature wich dave and ime “Translators name Signature with date and time Physician's name with employee [ID Signature with date and dime File location: Patient File Page 1/2cts Fo002/17 = or: 1312-2017: szibut brSbey Pepriseede dish tor pA At Kae porch boety bbe reo tLe Piast TL but UndleseieiSeor Sond NS ist Lutgbnd neh Gibb Be Sree SH, Ty folegie i is Ae Leis Sheree Mats Borer See tALte ay Luli uripzle Mounted wie Vy Erdine Sesto ble Eb Sot EL als enindrca het Feb e nese fipouast ae Moth ate Sb MASE Hob ML GueSond Metin Holset r6 nl 4M untslere sel sp PEL AEE hefoleght -2 Ph Bens bg tee ALI ERE AM IL By HLL StL Be Unsere 3 BE Sete tie burton rSka ras aeeseet eel 23. PSV | WE Lp owe col umd /eevertnSCg Mbit hate Gerlage A FPS oot Mite Lei iP Lig 0bL SOLvL Sound Mfuskeot 5 ATA HVE tlt roel fniMALat 6 btwis ibeudsele, PL, Cubist acs nce Orcas reer OTS KS — 7 Fie location: