Consent Waiver of Medical / Surgery: ST ND [PDF]

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CONSENT WAIVER OF MEDICAL / SURGERY I who signed under this : Name Age Gender Address Phone Relation to the patient



: ………………………………………………………………………………………........... : ……………. years old : Male / Female : ………………………………………………………………………………………........... : ………………………………………………………………………………………........... : ………………………………………………………………………………………...........



Patient's name Age Gender Address Phone Treated at Medical record number Pre-operation diagnose



: ………………………………………………………………………………………........... : ……………. years old : Male / Female : ………………………………………………………………………………………........... : ………………………………………………………………………………………........... : Room…………………...…… Class ………………… : : ………………………………………………………………………………………...........



Hereby agrees to be taken medical / surgery : ……………………………………………………………. Of the patient with / without general anesthesia / local. I make this statement with the fact that : 1. Explanation has been given by the doctor about the patient's disease, treatment options, and medical action / treatment as well as the dangers, risks, and possibilities for action arising from the medical, and fully understood the explanation given by the doctor. (...................... / initials ) 2. I also agreed to do further medical treatment, if necessary for the patient's safety. (………………………. / initials) Type of medical treatment / surgery : ……………………………………………………………………….. Type of examination patologi anatomy : …………………………………………………………………… Cibinong, ……………………………. Doctor who explain



That makes the statement



_________________________ Clear name



_________________________ Clear name



Ist Witnness (from hospital)



2nd Witnness (from family)



_________________________ Clear name



_________________________ Clear name