Informed Consent document Name :

Date of birth :
Medical record number :

Medical Action Approval

I am who signed below,
name
date of birth/age…….. Male/Female
address………….
I hereby express my consent to take medical action ……………………..
on (date)…………….. to me/to my…………………… named………………….., date of
birth/age……….male/female, address…………………..
I also realize that doctors will make efforts and because medical science is not an exact science,
the success of medical procedures is not a necessity, but very much depends on the permission of
the almighty God.

……………….. date ………………….. time …………….

person who stated doctor witness 1 (family) witness 2 (staff)

Refusal of Medical Action

I am who signed below,
name
date of birth/age…….. Male/Female
address………….
I hereby express my refusal to take medical action ……………………..
on (date)…………….. to me/to my…………………… named………………….., date of
birth/age……….male/female, address…………………..
I understand the need for and benefits of the medical action as explained above to me including
the risks and complications that may arise if the medical action is not carried out.

……………….. date ………………….. time …………….

person who stated doctor witness 1 (family) witness 2 (staff)