INFORMED CONSENT:

Dated: 17/09/2018

Patient party have been explained about the clinical condition of the patient and his neurological
and co-existing cardiac co-morbidities have been explained to them in their own language. They
wanted to discharge the patient against medical advice to Cardiac Set up for his further
management. They have been explained in their own understandable language that patient requires
in hospital care and needs to remain in close follow up. But they wanted to discharge and transfer
the patient to cardiac care set up despite explaining about the associated risks during and due to
transportation and risks arising from critical clinical condition of the patient. They have been
explained in their own language that under all foreseeable conditions if due care is not taken during
transportation, including continuous cardiac monitoring and continuation of cardiac medications,
Patient’s clinical condition might deteriorate any time and that he might succumb to death. On the
event of occurrence of any untoward incidence to this patient arising from the critical clinical
condition of the patient which can be further aggravated by transportation and shifting and
discharging the patient including death, NIMHNAS doctors, staffs, nurses cannot be held responsible.
Patient party is taking the patient against medical advice in their own responsibility, sound mind and
will without being subjected to any outside mental pressure, prejudice or coercion.

Recorded By: Patient Party: