Hospital

Part II. Undertaking

I…………………………………........................................................…….......................………
aged……...................years, residing at
………………………………………………………………………………………………………
………….....…………………………………………………………………
give my free and valid consent for
………………………………………………………………………………………………….....
…………………………………………………………………………………
(name of operation and /or medication /investigation / therapy/procedure etc.)
upon
myself/my……………......................................................................................................................
.............…… (relation)
(Mr./Mrs………………………………......................................................................................
………aged…....…years, residing at
………………………………………………………………………………………………………
….....…………………………………………………………………………
I am aware that the surgery will be carried out under the directions of
………………………………………………………………………………………… (name of
the doctor) and the team of doctors,
nurses, assistants.
I am aware that the anaesthesia will be administered under the instructions of Dr
…………………………………...................................................................................……………
(name of the anaesthesiologist)
I state that:
I. I have been explained about the nature of the disease that I am suffering from.
II. I have been given the information about the surgery by doctor. On …………. I
was also given a leaflet that had detailed information regarding:
a. nature and procedure of the surgery/ procedure
b. its purpose, benefits and effect;
c. alternatives if any available;
d. an outline of the substantial risks
e. adverse consequences of refusing treatment
I have gone through the details mentioned in clause 1-8 and have clarified my doubts
with the doctor.
III. I understand that during the course of the surgery, the doctor may find other
unanticipated, unhealthy conditions that may need specific actions / procedures/
surgery. If doctor feels that it will be beneficial to treat such condition while
performing proposed surgery and if I am not in the mental/physical capacity to give
consent, the doctor may take necessary decision after discussing with
Mr/Mrs………………………………(relation). I authorise the above mentioned person to give
proxy
consent on my behalf.

PART II : UNDERTAKING
PART II : Undertaking 1
148
IV. In order to save the life it may even be necessary to do additional surgeries or
procedures which are beyond the scope of the consent given by me. I authorise the
doctor to take such decisions if the need be.
V. I have been counselled about the nature of anaesthesia, benefits, purpose, effects and
alternatives and substantial risks.
VI. I understand that tissue, secretions, discharges, organs removed during surgery may
be sent for appropriate examination for further evaluation or dispose of as deemed fit
by the doctor.
VII. I give consent for blood /blood products transfusion. I have been explained about the
benefits, purpose, effects, alternatives and substantial risks associated with it.
VIII. I consent to observing, photographing or televising of the surgery for medical,
scientific, or educational purpose, provided my identity is not revealed by picture or
by descriptive text accompanying them.
IX. I accept that medical science is not perfect and has certain limitations. No guaranty
has been given about result or outcome.
X. I agree to co-operate fully with my doctor and to follow instructions and
recommendations about my care and overall treatment.
XI. I confirm that I have given accurate and relevant details about myself including past
medical history, previous ailments, surgeries and allergies to the doctor.
XII. Apart from the above mentioned general information, I have been specifically
informed about individual risks related to
………………………………………………………………………………………………………
………………………………………………………………………
……………………………………………………………………………………………….( to be
written physically by the doctor.
This refers to specific problems pertaining to that patient).
XIII. I was encouraged to ask questions related to disease and the procedure/operation. All
the questions/queries were answered to my satisfaction.
By signing below I indicate that I have understood the above information (point 1 -8 & I to
XIII) in the language that I understand.
I am giving my free consent willingly with sound mind, without any undue influence,
coercion, fraud, misrepresentation or mistake of facts.
PART II : Undertaking 2
149
………………………………………………………………………………………………………
…………………….....................................................................
………………………………………………………………………………………………………
………………………..................................................................
...
………………………………………………………………………………………………………
………………………...............................................................
(space for hand written declaration by the patient or relative in his or her language)
Sign
Dr.’s Name
Reg.no:
Date:
Time: AM / PM
Sign / Thumb impression
Patient Name:
Age years:
Date:
Time: AM / PM
Sign
Name of witness
Age years:
Address
Date:
Time: AM / PM
Sign
Name of witness
Age years:
Relationship with patien t
Address
Date:
Time: AM / PM
PART II : Undertaking 3
150