(PATIENT CONSENT FORM)
Please read the information carefully and tick the following to indicate you have understood and agree with the information provided to you. Any specific concerns should be discussed with your doctor or proceduralist performing the procedure prior to signing the consent form.

The doctor/proceduralist has explained my medical condition and prognosis to me. The doctor/proceduralist also explained the relevant diagnostic treatment options that are available to me. The risks of the procedure have been explained to me, including the risks that are specific to me and the likely outcomes. I have had an opportunity to discuss and clarify any concerns with the doctor or proceduralist. I understand that the result/outcome of the treatment/procedure cannot be guaranteed as per Medical council India norms & no guarantee can be provided that a particular doctor/staff. I hereby acknowledge that treatment I am undergoing has no refund policy. I understood that the treatment has success in most cases that undergo it, however, there may be cases who do not respond or who may not respond satisfactorily. If a staff member is exposed to my blood, I consent to a sample of blood being collected and tested for infectious diseases. I understand that I will be informed if the sample is tested, and that I will be given the results of the tests. I agree for my medical record to be accessed by staff involved in my clinical care and for it to be used for approved quality assurance activities, including clinical audit. I have been explained clearly the risks and benefits of the treatments. I also acknowledge that on account of behavioral misconduct abuse verbal or physical of any form to doctor, staff or at the clinic from my end, can lead to immediate termination of the treatment. This also includes harassment, bullying, intentional harm or misconduct in behavior in person and or on social media. I recognize that the practice of medicine is as much an art of science and therefore acknowledge that no guarantees have been made regarding the likelihood of success or outcomes of the treatment or about the sustainability of the results. As with any medical procedure or medical treatment, unforeseen complications could arise. I am aware of this fact & I acknowledge if such unforeseen complications arise, the doctor would neither be liable or held responsible for it. I consent to photography /Videography of the procedure to be performed for the purpose of records and to further medical education, awareness and research. I will regularly follow up with the doctor & clinic, I will keep the clinic and doctor aware about my current health conditions, blood investigations etc.

I acknowledge that I have had the opportunity to discuss and understand this Procedure, with my physician, in the language I understand, and hereby Consent to this procedure.

I consent to undergo the procedure/s or treatment/s as documented on this form.
(please tick appropriate box)
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