church of south india – rayalaseema diocese

CAMPBELL HOSPITAL
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HIGH RISK CONSENT

Patient’s Name:……………………………………………………………………………………….
Age:-………………………… Sex:-………………………………………………………………….
IP/Reg.No:-…………………………… Date:-…………………………….. Time:-………………
Address:-……………………………………………………………………………………………....
…………………………………………………………………………………………………………
Consultant Doctor:-……………………………………… Department:-…………………………...

I/We have been explained in detail that patient named …………………………………………… is

suffering from……………………………………………………………………………………….

The Condition of patient is quite serious. I/We have also been explained about the pros and cons of
the disease, its course, possible outcome and details of management. I/We have also understood
that during the course of his/her illness and its treatment, anything may happen to the patient
including the risk of life and / or death. Having understood these fully. I/We give our free consent
to the treat doctor………………………………………………………….and his team to proceed
with further management. I/We also give full consent to the doctors for any emergency procedures
like endotracheal intubations. CVP line, and cardio pulmonary resuscitations, etc.

I/We also agree for further referral to higher centre if needed.

Signature of the Doctor Signature of the Patient’s of the Attendant

Name:………………………… Name:-……………………………………..

Signature of the witness Relation:…………………………………...

1. ……………………………… Phone.No:………………………………….
2. ………………………………

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