A patient consent form is a document signed by a patient indicating that he gives consent for a particular action to be taken. Such actions could be like acknowledging the risks involved in undertaking certain medical procedures or tests. Below is a sample patient consent form.
Blood group: _____________
Insurance: _______________ certificate no/: __________
Special medical issues_________________________________
Last tetanus shot (Td) DD/MM/YY: __________/ ________ / _________
Medication allergies: ______________________________
History of Asthma Y__ N ___ History of seizers or other forms of unconsciousness Y __ N__
History of heart problems Y __ N __ If yes, nature of problem _____________
I __________________________________ do agree to take the following medical procedure ____________________________________ being fully aware of the risks involved. I take full responsibility of my decision and the consequences of the same.
Signed ___________date: ___________
Dr. ___________ date: ______________