Name: _____________________________

Pin No:_____________________________
Nationality:__________________________
Age:___________________Sex :________
Company: __________________________
Date of Admission: ___________________

GENERAL CONSENT
Patient’s Name:………………………………………Age:…………..…………...Marital Status:…..……..……..
ID type / #:... ………………………………………….Sex: ……………………… Nationality: …………….……..
Pin #: ..…………….…
Residence Tel. #: …………………………………….Mobile #:…………………...……………………. ………….
Sponsor's Name: ………………………………………………………………………………...………...…………
Sponsor's Address: ……………………………………………………………………………………….. ………….
Sponsor's Tel. #:.........................................................

Date of admission:……………………………………….. Time of admission:………………………… ………….

Unit: ………………………………………………………. Room / Bed #: …...................................... ………….
Diagnosis:…………………………………………………. Reason for Admission: ……………………………....
Physician in charge & ID ………………………………………………………………………………….

I, the undersigned, on behalf of myself / the patient, acknowledge that I have been informed by the treating
physician and responsible persons in the hospital of all my rights and obligations towards the hospital, which
are as follows:
1. The treating physician informed me of: the provisional diagnosis on admission; the reason for admission
with an explanation of expected investigations and procedures; the suggested treatment plan, treatment
alternatives, possible complications and it is of the opinion that this is the most suitable treatment plan;
expected length of stay in the hospital; the possibility that, due to changes in my condition, there may be a
need for further investigations or a change in the treatment plan and the physician will inform of this at the
time; my right to agree to or refuse suggested treatment or alternatives.
2. There is a clear hospital policy which acknowledges the patient's right to full information regarding
available services. Employees will utilize all hospital services/facilities to provide the best possible service of
the high quality that the public has come to expect, and according to medical criteria.
3. All services will be provided in accordance to cultural values, with consideration of the patient's right to
privacy, confidentiality, and protection of the patient and his belongings from any harm.
4. There is a clear hospital policy which takes into consideration the special needs of patients, whether in
special categories of diseases, severe symptoms such as pain and the special needs of critical cases, etc.
which protects the patient's right to diminished suffering and humane treatment in all situations.
5. The hospital will get the patient's/his or her agent's consent to all medical /treatment procedures, and
especially those relating to surgery and anesthesia.
I also acknowledge that I have been informed of the following:
1. The hospital administration is not responsible for money, valuables or personal belongings brought to the
hospital. In unavoidable cases, the protection of these belongings shall be my responsibility and not the
responsibility of the hospital.
2. I promise to pay all treatment expenses according to the prices and means determined by the hospital,
including the payment of a deposit – as insurance - on admission, as well as installments so that there will
always be credit in the patient's account. I agree to pay the balance of all expenses at discharge, except for
package deals in which case all expenses should be paid at admission.
3. I have been informed that the patient's room rate is billed until 12 midnight daily, and that I should vacate
the room before this time. If this cannot be done, then I agree that another night be billed on my final
account.
4. In case I do not present an endorsement letter from ……………………………………, which is the party
responsible for the account, I thereby take personal responsibility for all treatment expenses.
5. In case of admission of emergency cases, I will be fully responsible to transfer my patient once his
condition is stabilized and the risk is cleared.
I certify:
Name: __________________________________ Witness: ___________________________
Signature: _______________________________ Signature: __________________________
Relationship: _____________________________ ID: _______________________________
Date / / Time : ______________
Witness: ___________________________
Name of Doctor: __________________________ Signature:__________________________
Signature: _______________________________ ID:________________________________
 Date / / Time: ________________
2010-CONS-FM-004