Self Assessment
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INFORMED CONSENT
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INFORMED CONSENT
1. I hereby authorize and direct Dr
and the associates or assistants of his/her choice to perform theConsultation, Laboratory and Radiology investigations and Treatments,therapeutic injections/vaccinesand procedures as his or their judgment may indicate on the said operation and procedure.
2. I have conferred with the said doctor or other doctors about the nature and purpose of the operation or procedure and the possibility that complication may arise or develop risks which may be involved and possible alternate methods of treatment.
3. I authorize and direct the above-named doctor and/or his/her associate and assistant to provide such additional services as they seem reasonable and necessary including but not limited to the administration and maintenance of anesthesia and the performance of services involving pathology and radiology.
4. Any tissues or parts surgically removed may be retained or disposed of by this clinic in accordance with its accustomed practice.
5. I Agree to settle the professional fee arise after the completion of my Consultation / Treatments / Procedures and all additional expenses and charges.
6. I have faithfully followed the pre-operative instruction given by the above-named doctor. Having received an explanation and given informed consent, I hereby agree and release this clinic, its doctors, employees and dental staff from further responsibility with regards to permission for this operation or procedure and the outcome thereof
Patient Name
Patient Signature
Date/Time
Relationship of the signatory to patient:
If patient is a minor, name of patient or guardian:
Complete the following:
Where the patient is incapable of signing and another person signs instead, indicate why the patient is not able to give consent personally or sign this form.
Minor
Unconscious
Physical Condition
Other
Doctor Name
Signature
Date
Witness Name
Witness Signature
Date
Patient Signature
Witness Signature
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