WRITTEN WHOLE INFORMED PRE POCEDURAL CONSENT FORM

SELF DECLARATION/ CONSENT FORM

I/my patient _______________________ Age ______ S/D/W/o ______________________

is suffering from ____________________________________________________________
_________________________________________________________________________
___________ symptom(s) for last _____________________ time, has been diagnosed as
a case of ___________________
_________________________________________________________________________
_________________________________________________________________________
____________ for confirmation/diagnosis/treatment/relief/betterment/complication treatment
of which, I/we hereby give my/our full informed consent/authorization as an act of my own
free will and i/ my patient want to under go
_________________________________________________________________________
_________________________________________________________________________
___________________________procedure to be done by Dr. __________________
under ______________________ anesthesia by Dr. __________________ & his chosen
team, members/assistant/helpers team being selected by him/her. All the
benefits/risks/complications/side effects etc. have been discussed and explained to me
details with adequate time.

We understand the meaning of these diagnosis and the other possible differential diagnosis
explained to us in detail including the possible complications, possible further progress of
disease, with and without various treatment options for all of them and that
following__________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

1
_______________________ are the other probable differential diagnosis of my patient,
which are likely to be the possible correct diagnosis, if the most probable diagnosis comes
out to be wrong.

In case Aforesaid mentioned procedure(s) is/are not done because of some technical/intra-
operative findings related reasons then ________________________________________
_________________________________________________________________________
____________ OR SOME OTHER APPROPRIATE alternative procedure(s)/ treatment
will be done, I/we give our full informed consent for this decision to be completely taken by
our doctor & his team based on their knowledge, experience and judgment during the ongoing
procedure/ treatment

i/ we understand that after the planned treatment or procedure is done or it partially or

completely fails/ is unsuccessful, then same or other or one of the following secondary/
supplementary procedure(s) / treatment options or like  Radiotherapy/  chemotherapy,
__________________________________
_________________________________________________________________________
may be required to be followed in order to complete or further proceed in my/ patient’s
treatment and we will give our full support to treating doctors in this or whatever is required to
save patient’s life and to treat the disease. And we assure/ declare that we will complete these
secondary/ supplementary treatments/ procedures if required which may need to be done at
same or other hospital/ institute/ Centre, and will not blame our doctors if we do not complete
the treatment at any stage for any reason.

I/we understand that the disease process have following known side effects/
complications/ harmful effects on my/patient's body/ organs
_________________________________________________________________________
_______________________________________________________ I also hereby consent

2
to disposal/ with or without any kind of chemical/ biological treatment on any of the partially
or completely diseased/unwanted tissues/other body parts/ partial or full organ which may
be removed during the course of the procedure being done including
_________________________________________________________________________
_________________________________________________________________________

I/we understand that the procedure being done may involve the selected from following 
Anesthesia  Sedation  Artificial ventilation  Medications  various Injections - infra
venous or intra muscular or intra/ extra thecal  use of various instruments  Blood or its
products transfusion.

i/ we understand that some of the important goals of the procedure / treatment being carried
out/ partially or completely mentioned above
are______________________________________________________________________
_________________________________________________________________________

i/ we understand that Procedure involves dissection/ separation of diseased tissues/organs

from normal tissues/ organs using complicated measures/steps to achieve above mentioned
goals. This procedure and utilized medicines/instruments are associated with side
effects/risks/ complications/injuries to tissues/organs, which may or may not be predicted
before surgery or predicted only to a very limited extant. Some of them are enumerated below.

Injury to normal organs which may or may not result in partial or total organ failure. Finding
unpredictable anatomy/ excessive adhesions between diseased & normal tissues, which may
not be predicted by any imaging etc. investigation. Other complications:

 failure of complete surgery/procedure  recurrence of disease  inability of an

organ/organ system(s) to be able to withstand surgical /anesthesia process resulting in their
failure/malfunction.  spinal headache  spinal shock  abnormal reaction of organs

3
towards medicines/drugs used  Bronchospasm (Breathing Difficulty)  Breakage/failure of
implant  failure of bone/nerve/vein Artery/organs to heal  Joint immobility 
failure/breakage of sutures/re pair  Pus formation  Heart failure  Kidney failure 
Respiratory failure  Liver failure  Intestinal fistula  Death  sepsis
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
______________________________________________ we understand that doctors are
not responsible for these complications as they try their best to avoid these as much as
possible and we declare that WE FREE OUR DOCTORS/ HOSPITAL from any liability for
these and we declare that in case anyone are more of these happen we will accept them, and
help our doctor in treating them.

(Organs mean Heart, Liver, Kidney, Lungs, Nerves, Arteries, Veins, Bones, Musculoskeletal
System, Intestines, Skin, perineum, Spleen, Blood organs system, Joints other organs etc.)

We understand that all differential diagnosis/ planned procedure/ planned treatment, tests,
etc are based on available scientific knowledge that has reached to my treating doctors
according to the society’s conditions and even with the best efforts from my treating team of
doctors and allies, the diagnosis and information about patient collected from various
investigations and tests may be completely or partially incorrect, and we do not blame the
doctors as responsible for these factors or there consequences. I/we understand that all the
investigations only give very limited information and intra operative findings may be
significantly or totally different.

We understand that other than the treatment procedure, I/my patient will have to take
following precautions like Avoiding smoking /tobacco/Alcohol etc. Avoid weight
lifting/straining of operated site, to have diet as advised to me by my doctor, to follow

4
exercises/ lifestyle as advised to me, to maintain personal hygiene specially of operated site
and
_______________________________________________________________________
_________________________________________________________________________
____________ etc. i/ we declare/ promise to follow them.

I/ we understand that NOT following the above mentioned precautions diligently, may result
in complications like  Infection  Recurrence of Disease  Infection  Failure of
treatment  Bleeding  Suture /Repair breakage  Joint contracture/ immobility 
Chances of above mentioned complications,  Complications mentioned related to treatment
procedure and
_________________________________________________________________________
_______________________________________________________

I/we understand that all the services of hospital, doctors contributing to my/patient's treatment
are only a small part of possible treatment options/facilities/services and these can be made
better, safer but it is my whole informed decision to be treated by these available, chosen
treatment services/ doctors/ medicines in available circumstances budget and I do not /will
not blame doctors/hospital for not providing or not choosing other treatment services that
are not being used in my treatment at present like ______________
_________________________________________________________________________
and we do not consent for any change in the present circumstances even if they can improve
the outcome.

I/we understand that in case of probable or organ complications/ unfavorable or other

circumstances I/my patient may be shifted/ referred to higher center/ other hospital and in
such scenario we will co-operate in the same, as advised by the doctors.

5
I/we understand that doctors & their team are treating me/ my patient selflessly/ without any
selfish Intentions and even after their best whole hearted efforts, complications/difficulties/
unfavorable circumstances/side effects/adverse events etc. are possible with any doctor/any
hospital including the best of the best ones and no doctor can guarantee the success of
treatment or no complications. We assure that we have full faith in doctors and staff of
PODDAR NURSING HOME and none of the staff/doctors here have any bad/wrong intentions
towards any of us.

I/we understand the success/failure/complications/outcome of treatment depends

upon many known & unknown reasons like difference in anatomy, not known/ detected/
investigated status of patient's body, hidden/Latent/sub-clinical disease in
organs/Lungs/heart/Liver/Kidneys/blood etc, my/ my patients’ bad/ non ideal Lifestyle/habits,
inadequate physical/nutritional activities, etc. Such factors cannot be estimated or predicted
beforehand because of reasons like limited information/ knowledge available to my doctors
because of or related to circumstances not allowing more tests, limited knowledge of
science and available worldwide scientific research, inability of any possible investigations
to measure/predict there factors or other un-explained factors. Because of these, the
disease process and treatment services and medicines have a very significantly different
and unpredictable effect on every different patient and capability of organs to bear the
effects/harmful effects of medicines/anesthesia drugs/surgical process is different in every
patient and capabilities of organs varies significantly, and even after following all scientific
protocols, organs failure/complications can happen without being able to be predicted which
may even lead to events morbid enough to result in death or death like situation. The final
outcome of disease and treatment procedure depends upon such known and unknown
natural, artificial factors and whatever the outcome is good or worst, we do not blame or
credit the hospital or doctors for any untoward or unfavorable consequences or results that
may arise because of these factors as doctors are doing their duty by giving their best
possible efforts in treating me/my patient and we as a team in spite of our best efforts
cannot have full control on the outcome.

We acknowledge/ declare that we are indebted to our doctors for the efforts TO BE put in
by them, which cannot equaled by any materialistic things including money, and even in case
of failure to provide reasonable level of care/ skills/ service also any form of compensation in
6
the form of money/ other materialistic/ non materialistic things or any form of punishment will
not be demanded by me/ us and we promise to forgive and not blame them for any human
mistakes done by them without any wrong intentions knowing that mistakes are always
possible by any human being in whatever position/responsibility he may be holding, we
promise to accept any outcome that finally happens are a result of the effects of disease
process and treatment procedure.

I/we understand that treatment procedure and its result depend upon natural &
environmental factors some described above, on doctors, staff, medicines from various
pharmaceutical companies, generic or branded, nurses, instruments made by companies.
These factors are controlled by different individual on which hospital or doctors have a very
limited or no control at all and any of these are bound to make human errors/ technical errors
etc, which can happen with any human being/ machine; in such case we promise to forgive
them for any mistake not done by wrong/ bad intentions/ intentions to cause harm etc and we
will cooperate with doctors/ hospital staff in treating any complications because of such errors.

I/we understand that treatment procedure/surgical procedure is done with the help of very
complicated combinations of fine steps with great responsibility and difficulty by trained
experts and during these fine complicated steps, mishaps/advert events, further
complications are likely to happen even with the best of best doctors of all parts of the
world including failure of treatment, even death of patient, and knowing the previous
qualification/experience, surgical success rate etc. we take this whole informed decision to
get treated from this team of doctors, and we share responsibility of outcome of treatment
which depends upon this factor.

i/we declare that we trust all decisions made by our doctors based on there scientific and
practical knowledge and on there experience, this knowledge may not be updated fully with
recent updations. We understand that these decisions can result in good as well as bad or

7
partially good or partially bad outcome and we trust scientific background that our doctor use
to make these decisions as my/ my patients knowledge is not enough to fully understand
them, we do not and will not blame our doctors for any consequences because of these
factors.

I/we understand that there are other doctors whose degrees, qualifications, experience,
treatment success rate, skills etc may be significantly more or less than our team of doctors
and we also have better or cheaper hospital/medical colleges/institutions etc centers, details
of these we have enquired, discussed and understood according to our satisfaction and we
know that we are free to take consultation/treatment from them but we do not want to take
treatment/ consultation/ or any service from them until unless our team of doctors want so
because of our own personal reasons which may include financial/ social/ emotional reasons
etc also and we have chosen this team of doctors whose qualification, experience, treatment
result success rate etc are very well understood by us & PODDAR NURSING HOME whose
facilities, services, investigations, available doctors, specialties, are very well clearly
understood by us, we do not have any doubt on our decision and we do not or will not blame
doctors for this factor's effect on outcome, because doctors are treating me/my patient with
best of their knowledge & efforts without any bias, in the available facilities & circumstances.

We have been made aware of details of all tests, VARIOUS treatment RELATED services,
medicines, there AVAILABILITY, NON AVAILABILITIES, side effects, harms, benefits,
purposes, risks etc within the limit of our understandability and we give our whole informed
consent to doctors to use treatment services, medicines as required according to situation.

If needed additional consultation from other experts/specialists/super specialists may be

taken, and we are ready to bear those extra expenses, and we promise to keep asking and
clearing any doubt/query about changing status of my patient his/her disease/treatment etc
on timely basis and daily basis.

8
I/we consent for removal disposal and various testing of blood/urine/plasma/body
fluids/tissues/organs/body part etc. before, during and after treatment procedures as required
by doctors/team/hospital.

I/we will bear the responsibility of any damage/harm/breakage to hospital

things/belongings/staff/doctors if done by patient or any of the visitors/attendants to our
patient and will pay for the same if asked for.

I/we are fully aware that all medicines/instruments/machines etc. are purchased from outside
manufactures and none of these are manufactured in/by PODDAR NURSING HOME Pvt.
Ltd.

I declare that I am/ am not suffering from allergy to any substance. If I am, the description
is________________________________________________________________________
___________

I/we understand, consent, and share the responsibility for the decision that in the available
circumstances and AS PER GUIDELINES only few medicines have been/ could be tested
for allergy and majority of medicines have not been/could not be tested for allergy and we
do not want to change this decision, we do not consider hospital or doctors personally
responsible for the consequences resulting from these factors.

I/we understand that allergic reaction/serious adverse events including one or more organ
failure, and even death can happen because of one or more of the medicines/implants/
sutures /treatment services used before during or after the treatment procedures this reaction
may happen even if allergic test to it is negative, and this reaction/adverse event may be very
rapid and so severe that even best of care & treatment, it may not be possible to save
my/patient's life/morbidity. I/we understand that doctors/hospital/nurse etc. are not
responsible for such events and we declare/promise to co-operate with doctors/hospital in

9
managing such crisis in all ways including financial/emotional/social etc. means, managing
this may require administering emergency medicines, blood or its transfusions, operation/
surgery, invasive procedures from more departments, consultants/specialists/super specialist
and we give our whole informed consent for all these and we want and declare that doctors
and hospital to take all decisions in such situation to achieve best possible outcome.

I consent for photographing/video filming of the procedures/body part/etc. for the purpose
of advancing medical education, its publication in scientific journals, presentation to other
doctors provided my/patient's identity is not revealed by the images/descriptions, I consent to
the admittance of qualified observers to the operation/procedure room, who have been
chosen/authorized by my doctors/PODDAR NURSING HOME Pvt. Ltd.

I/we know that in the case of lack of satisfaction or any other situation I/we are free to leave
PODDAR NURSING HOME , at any time and PODDAR NURSING HOME and doctors, staff
are free to send/refer/discharge/stop my/patient's treatment at any time in case of lack of co-
operation/bad behavior or any other situation/reason.

I/we understand that PODDAR NURSING HOME Pvt. Ltd. is a private hospital which runs
on expenses/finance provided by patient/relatives/attendants, we are aware of all the
charges/fees/expenditure etc. charged by PODDAR NURSING HOME Pvt. Ltd. and we
declare/ promise to pay all the fees/expenses/changes required by PODDAR NURSING
HOME Pvt. Ltd. which may more or less than the estimate of expenses told to us, which is
Rs. _______________. i/we understand that this fees is for the services provided by doctors,
staff hospital, consumables, non-consumable things utilized during the admission/ procedure
etc and result or outcome of the services/ treatment etc do not affect it in any manner.

I/we hereby declare that I/we have been given adequate time/opportunity to clear all my/our
queries about my disease/test results/treatment.

10
I hereby release the Hospital, its attending Doctors, Anesthetists, Pathologists, Radiologists
and its staff and all other person participating in my care from any liability whatsoever for any
untoward or unfavorable consequences or results that may arise out of or in the course of my
treatment (including surgery and anesthesia) at this Hospital which may be or may not be
related to any of the factors mentioned in this entire declaration/ consent form. And i/we
declare that even in case if this hospital and/ or this team of doctor(s) are not able to provide
reasonable level of care/ skills/ service to me/ my patient i/ we do not and will not blame any
of them for this or for any of its resulting consequences as it is our free will decision to undergo
this treatment/ procedure at this hospital by this/ these doctor(s). i/ we declare that during this
treatment/ procedure, if any kind of loss happens to me/ my patient because of any possible/
mentioned/ not mentioned reason(s) i/ we free/ release all of these doctors/ hospital/
associated staff from any kind of liability because this is being done with a intention of help.

I/we declare/acknowledge that all the information provided by me is complete and true to
the best of my knowledge and belief and no material information has been cancelled or falsely
told. I/we shall not hold the doctors/team/ PODDAR NURSING HOME Pvt. Ltd. or any person
associated with them responsible for any consequences which may arise due to any non-
disclosure/ incorrect disclosure of facts by me/ us.

I/we declare that all the information/statements/terms/words written in this form have been
understood by me, (explained, discussed to me), in language understood by me, and all
vacancies filled, cancellations/corrections done before taking my signature/thumb impression.

I/we declare that a copy of this form has been provided to me/ us.

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

11
During the course of treatment if i/ my patient is not in a state of giving consent for any
change/ addition in treatment then on behalf of patient _______________s/ o
_______________ undersigned ________ is authorized to give all consents and
authorized to take all decisions on behalf of the patient for the patient for maters related
to this disease and this treatment/ procedure.

This consent is valid for 48 hours after time of signature of patient/relative/representative.

Translated to __________________ language by Mr. ______________________

Patient/Representative's Signature/_____________________ Name__________________

Thumb Impression

Date:______________ Time: ____________ Relation - Patient ______________________

Witness's Signature\Thumb Impression __________________Name__________________

I have discussed/ explained all of the above to the undersigned patient/ attendants/ relatives
giving adequate time, attention.

Doctor/ surgeon's Signature: _______________ ANESTHETIST’S SIGN_______________

12