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High Risk Consent

This document is a High-Risk Consent Form for patients undergoing a procedure or surgery. It outlines the patient's acknowledgment of the risks involved, including potential complications and the voluntary nature of their consent. The form requires signatures from the patient, witnesses, and the doctor to validate the consent process.

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drpunia731
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9 views2 pages

High Risk Consent

This document is a High-Risk Consent Form for patients undergoing a procedure or surgery. It outlines the patient's acknowledgment of the risks involved, including potential complications and the voluntary nature of their consent. The form requires signatures from the patient, witnesses, and the doctor to validate the consent process.

Uploaded by

drpunia731
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

High-Risk Consent Form

Patient Name: _______________________


Age/Sex: ___________________________
Hospital ID/Reg. No.: _______________
Address: ___________________________
Date: ______________________________

Procedure / Surgery Planned:


_____________________________________

Diagnosis:
_____________________________________

I, ____________________ (patient name) son/daughter/wife of ____________________, aged


______ years, resident of ____________________, hereby declare that:

1. I have been explained in detail by Dr. ____________________ about my present illness, the
procedure/surgery advised, its benefits, limitations, and alternative options.

2. I have been informed that this is a HIGH-RISK case due to:


- ___________________________________
- ___________________________________

3. I have understood the possible risks and complications, which may include but are not limited to:
- Bleeding
- Infection
- Damage to surrounding organs
- Anesthesia-related risks
- Worsening of current condition
- Permanent disability
- Death

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High-Risk Consent Form

4. I have been given an opportunity to ask questions, and all my queries have been answered to my
satisfaction.

5. I understand that despite the best possible care and efforts, complications may occur, and the
outcome cannot be guaranteed.

6. I voluntarily give my consent for the procedure/surgery, understanding the above risks.

Patient's Signature/Thumb Impression: ____________________


Name: ___________________________
Date: ____________________________

Witness 1 (Name & Signature): ___________________________


Witness 2 (Name & Signature): ___________________________

Doctor's Name & Signature: ___________________________


Date: ____________________________

Page 2

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