High Risk Patient Consent Form

High Risk Patient Consent Form

Patient Agreement to Investigation or Treatment
This consent must be taken - in case of serious / complicated / risky / new - surgeries / procedures; for removing any organ; in high risk patients; for proceeding with a surgery / procedure in spite of any abnormal parameters of the patient. This list is indicative not exhaustive and in case of a dilemma it is always advisable to take this high-risk consent and not a general consent.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Male Female

Select
Patient Number
Responsible Health Professional
Job Title
Special requirements
Name of proposed procedure or course of treatment
Statement of health professional (to be filled in by health professional with appropriate knowledge of proposed procedure).
I have explained the procedure to the patient, in particular, I have explained, the following intended benefits:
The significant, unavoidable or frequently occurring risks:
Any extra procedures which may become necessary during the procedure:
Other procedures (please specify)
I have also discussed what the procedure is likely to involve, the benefits and risks of any available alternative treatments (including no treatment) and any particular concerns of this patient. This procedure will involve:

General anaesthesiaLocal anaesthesiaSedation
Material risk(s) of the proposed treatment / intervention / procedure / surgery:

I have been explained and have understood that the proposed treatment / intervention / procedure / surgery has certain material risks / complications and I have been provided with the requisite information about the same.I have also been explained and have understood that there are other undefined, unanticipated, unexplainable risks / complications that may occur during or after the proposed treatment / intervention / procedure / surgery.I state that the doctor-in-charge / principal surgeon / principal interventionist has answered all my questions to my satisfaction regarding the proposed treatment / intervention / procedure / surgery.I have been explained and have understood that despite the best efforts there can be no assurance about the result of the proposed treatment / intervention / procedure / surgery. I further state and confirm that I have not been given any guarantee or warranty about the results of the proposed treatment / intervention / procedure / surgery.I have been explained and have understood that despite all precautions, complications may occur that may even result in death or serious disability.I have been explained and have understood that the proposed treatment / procedure / surgery is uncommon / complicated / risky.I have been explained and have understood that the proposed treatment / procedure / surgery is based on technique / procedure / drug / protocol that is relatively new.I have been explained and have understood that the proposed treatment / procedure / surgery has a high rate of failure.I have been explained and have understood that the proposed treatment / procedure / surgery has high rate of relapse and recurrence.I have been explained and have understood that the proposed treatment / procedure / surgery generally require multiple sessions / sittings and I give my consent for the same.I have been explained and have understood that the proposed procedure / surgery generally require second intervention and I give my consent for the same.I have been explained and have understood that the proposed procedure / surgery generally requires further corrective surgery / procedure to deal with known post-procedure / surgery complication(s) and I give my consent for the same.I have been explained and have understood that the proposed procedure / surgery generally requires ‘re-exploration’ and I give my consent for the same.
Multi-stage treatment

I have been explained and have understood that the proposed treatment / procedure / surgery is a multi-stage treatment / procedure / surgery and I do hereby consent for each and every stage of the same.I have been explained and have understood that I may need long-term treatment.I have been explained and have understood that I may need long-term follow-up care.I have been explained and have understood that I may need longer period for recovery.
Signature

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Date

MonthDayYear
Date
Name

First NameLast Name
Job Title
Statement of interpreter (where appropriate)

I have interpreted the information above to the patient to the best of my ability and in a way in which I believe she/he can understand.
Signature

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Name

First NameLast Name
Date

MonthDayYear
Date
Statement of patient
Please read this form carefully. If your treatment has been planned in advance, you should already have your own copy, which describes the benefits and risks of the proposed treatment. If not, you will be offered a copy now. If you have any further questions, do ask - we are here to help. You have the right to change your mind at any time, including after you have signed this form.
- I agree to the procedure or course of treatment described in this form.
- I understand that you cannot give me a guarantee that a particular person will perform the procedure. The person will, however, have appropriate experience.
- I understand that I will have the opportunity to discuss the details of anaesthesia with an anaesthetist before the procedure, unless the urgency of my situation prevents this (this only applies to patients having general anaesthesia).
- I understand that any procedure in addition to those described on this form will only be carried out if it is necessary to save my life or to prevent serious harm to my health.
- I have been advised of the option to take a second opinion from another doctor regarding the proposed treatment / procedure / surgery.
- I state that after explaining, counseling and disclosures I had been given enough time to take decision for giving consent.
- I have signed this consent voluntarily out of my free will and without any kind of pressure or coercion.
I have been told about additional procedures which may become necessary during my treatment. I have listed here any procedures which I do not wish to be carried out without further discussion, even if I become at risk of death:
Patient’s Representative - If patient is incapacitated and unable to communicate in the future, further directions should be taken from the following person:

First NameLast Name
Relationship
Mobile Number
Signature

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Date

MonthDayYear
Date
Please select from the following:

I consent to the removal of my tissue and/or blood products during this operationI do not consent to the removal of my tissue and/or blood products during this operationI consent to its use for research in connection with disorders and/or the functioning of the human bodyI do not consent to its use for research in connection with disorders and/or the functioning of the human bodyI consent to obtaining scientific or medical information about a living or deceased person which may be relevant to any other person (including a future person)I do not consent to obtaining scientific or medical information about a living or deceased person which may be relevant to any other person (including a future person)
Patient's Signature

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Date

MonthDayYear
Date
Name

First NameLast Name
A witness should sign below if the patient is unable to sign but has indicated his or her consent. Young people / children will need a parent to sign here.
Signature

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Date

MonthDayYear
Date
Name

First NameLast Name
Should be Empty:

High Risk Patient Consent Form

Statement of health professional (to be filled in by health professional with appropriate knowledge of proposed procedure).

Statement of patient