Patient Consent Form

June 17, 2011

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.
Patient’s details

Name: ___________________

Blood group: _____________

Insurance: _______________                                        certificate no/: __________

Group: __________________

Medical history

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: ______________

 

Download Patient Consent Form in Word Format

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