CONSENT TO SURGERY

1. I hereby authorize Dra. Eli Tacad, MD and the staff of Northside Doctors Hospital
(Siak palubosak ni Dr. ken dagiti staff ti Northside Doctors Hospital

to perform _Appendectomy and such additional operations and procedures as are

nga mangaramid (Operation or Procedure) ken amaman nga operasyon ken “procedures”

considered necessary on the basis of there being a threat to life found during the course of said
operation to
mapanggep ti pagsyaatan wenno saan nga pagdaksan iti biag ti pasyente bayat ti pannakaoperar ni

P. K , who is my Son
Myself or name of Patient (Nagan ti pasyente) isu nga Relationship (panakaibagi)

2. The nature and purpose of the operation, the risk involved, and the possibility of complications have
been
(iti maited nga pagsayaatan ti operasyon, ken narisgo nga mapasamak ken posibilidad nga komplikasyon ket

explained to me in my dialect or in a language which I understand. I acknowledge that guarantee has

been made
naipakaammo iti pagsasao nga naawatak. Awatek nga adda garantisado ken nasayaat

as to the results that may be obtained.

nga resulta na.

C. K P. K
Signature of Witness over Printed Name Signature of Patient over Printed Name
Or person giving free consent
01/04/2021

Date

This authorization must be signed by the patient or by the next of kin in the case of a minor or where the patient is physically
or mentally incompetent.

Patient is a minor of years.

Patient is unable to sign because ________
 CONSENT TO ANAESTHESIA

1. I hereby authorize Dr. Roy Tacal, MD and the staff of Northside Doctors Hospital
(Siak palubosak ni Dr. ken dagiti staff ti Northside Doctors Hospital

to give General ___ anaesthesia to enable the surgeon to perform operation to

(Spinal, regional, general) pammaturog tapno maaramid ti siruhano ti operasyon kenni

P. K , who is my Son _____

Myself or name of Patient Relationship (panakaibagi)

2. The nature and purpose of the operation, the risk involved, and the possibility of complications have
been
(iti maited nga pagsayaatan ti operasyon, ken narisgo nga mapasamak ken posibilidad nga komplikasyon ket

explained to me in my dialect or in a language which I understand. I acknowledge that guarantee has

been made
naipakaammo iti pagsasao nga naawatak. Awatek nga adda garantisado ken nasayaat

as to the resullts that may be obtained.

nga resulta na.

C. K P. K
Signature of Witness over Printed Name Signature of Patient over Printed Name
Or person giving free consent
01/04/2021

Date

This authorization must be signed by the patient or by the next of kin in the case of a minor or where the patient is physically
or mentally incompetent.

Patient is a minor of years.

Patient is unable to sign because