Consent Waiver Of Medical / Surgery: st nd

CONSENT WAIVER OF MEDICAL / SURGERY I who signed under this : Name

: ……………………………………………………………………………………….........

Age

: ……………. years old

Gender

: Male / Female

Address

: ……………………………………………………………………………………….........

Phone

: ……………………………………………………………………………………….........

Relaon to to th the pa paent

: …… ……………………………………………………………………………………….... ........

Paents name

: ……………………………………………………………………………………….........

Age

: ……………. years old

Gender

: Male / Female

Address

: ……………………………………………………………………………………….........

Phone

: ……………………………………………………………………………………….........

!reated at

: Room…………………...…… "lass …………………

Medi#al re#ord num$er

:

Pre% Pre%op oper era aon diag diagno nosse

: …………… ……………… ………… ………… ……… …………… ……………… ………… ………… ………… ………… ………… ……… …………… ………….. .... .... .... ....

&ere$y agrees to $e ta'en medi#al / surgery : ……………………………………………………………. ……………………………………………………………. () the paent with / without general anesthesia / lo#al. I ma'e this statement with the )a#t that : *. 0,planaon has $een gi1en $y the do#tor a$out the paents disease- treatment oponsand medi#al a#on / treatment as well as the dangers- ris's- and possi$ilies )or a#on arising )rom the medi#al- and )ully understood understood the e,planaon gi1en $y the do#tor. do#tor. 2...................... / inials 3 +. I also agreed ag reed to do )urther medi#al treatment- i) ne#essary )or the paents sa)ety. sa)ety. 2………………………. / inials3

!ype o) medi#al treatment treatment / surgery : ………………………………………………………………………. ………………………………………………………………………. !ype o) e,aminaon patologi anatomy : ………………………………………………………………… "i$inong- ……………………………. o#tor who e,plain

!hat ma'es the statement

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Ist 4i  4 itnness 2)rom hospital3

+nd 4itnness 2)rom )amily3

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