HIG RISK CONSENT (draft - 1)
I/We the patient attendees have been explained in our own understandable language about the
condition of the patient that
is_________________________________________________________
I/We have been explained in our own understandable language about the undergoing surgery
that is ____________________________________________________________
And its associated complication such as infection, bleeding, sepsis, MODS, AKI, residual stone,
recurrent hypotension, electrolyte imbalance, ICU admission, need for blood and blood
products transfusion, cardiopulmonary arrest and even death.
I /We have been explained about the condition and need for surgery and do not hold
treating doctor/ hospital staff responsible for any untoward outcome including death.
Date: Time:
Witness 1. Signature
Relationship
Witness 2. Signature
Relationship
:
CONSENT FOR HIGH RISK (draft 2)
Date
I_________________________________________________________ have been explained about the
following medical edition and the proposed surgery by Dr.
__________________________________Primary Disease.
_____________________________________________________________________________________
___________________________________________________________________________________
Name of the procedure / Operations.
_____________________________________________________________________________________
_____________________________________________________________________________________
I have been explained about the following
1. Associated Risk Factors
_____________________________________________________________________________________
______________________________________________________________________________
2.
Complications_________________________________________________________________________
_____________________________________________________________________________________
In view of the above, I have been explained the risks of not having the procedure and that the proposed
surgery carries a higher risk than normal including risk to life
I have been informed that I might need intensive care treatment after the procedure.
I have been explained the likelihood of success & surgery/procedure, possible problems related to
recovery and possible results of non-treatment in the language understood by me.
Having understood the above in the language I understand, I give my High Risk consent absolve Sigma
Hospitals Mysore, Its doctors and the staff in the event of any complications
Patient _____________________________________________________________ Date_____________
Witness __________________________________Relationship________________ Date_____________
Doctor ______________________________________________________________Date_____________
CONSENT FOR HIGH RISK (Draft- 3)
I/We the patient attendees have been explained about the condition of the patient i.e, Left
upper ureter stricture and s/p CABG with LV dysfunction (ef-37%)in our own under stable
language.
I/We the patient attendees have been explained about the above mentioned condition and
need for surgery i.e, laparoscopic BMG urethroplasty
And its related complications such as bleeding infection sepsis, graft necrosis, graft failure,
incontinent need for re-do surgery , recurrent prolonged hospital stay, need for blood
transfusion , ICU admission, ventilator support, anesthesia related complications seen as
Hypotension, hypertension, cardio respiratory arrest erectile dysfunction and death can occur
I/We attendees of the patient understand the condition, surgery and complication associated
with it.
I/We have given valid written consent and will not hold any treating doctor, staff and hospital
administration during surgery or post surgery
Date: Time:
Witness 1. Signature
Relationship
Witness 2. Signature
Relationship