Taoyuan Veterans Hospital, VAC, Executive Yuan
佐證 2-1-6
CONSENT TO SURGERY AND ANESTHESIA
Date:
Medical Chart#:
To: Taoyuan Veterans Hospital, VAC, Executive Yuan,
, the Patient, Gender
,born on
, has suffered from the disease
of
, which requires surgical operation of
. For the disease,
Dr.
of Taitung Veterans Hospital (who signs in person hereunder) has explained to me in
person the following facts. I,
, the undersigned, hereby confirm my full understanding of
such facts and further confirm consent to the surgical operation oriented anesthesia Taitung Veterans
Hospital conducts on the Patient:
I.
II.
III.
The reason for operation
The success rate of operation
The complications and risks possibly resulting from the operation and anesthesia (Cf. Explanations
on Anesthesia provided on another page).
In the process of the surgical operation oriented anesthesia, Taitung Veterans Hospital is supposed
to exercise due diligence in medical treatment as required. In case of an emergency taking place
during the process of surgical operation oriented anesthesia or anesthesia convalescence, I agree to
accept all emergency treatment which Taitung Veterans General Hospital considers necessary.
Consented by:
(Signed with seal)
ID No.:
Address:
Telephone:
Relationship with the Patient:
Remarks:
I.
This Consent is to be signed by the Patient in person. Where the Patient is a minor or unable to sign in
person, the Consent may be signed by a relevant person as defined by Article 46, Paragraph 1 of the
Medical Treatment Law.
II.
Where the Consent is signed by a person other than the Patient, the relationship with the Patient shall be
entered in the space of “Relationship with the Patient”.
III.
In the event that another surgical operation is required after the patient receives the surgical operation, the
surgical operation shall not be conducted until another consent is duly signed in accordance with the
procedures herein except an emergency defined under Article 46, Paragraph 1 of the Medical Treatment
Law.
Article 46, Paragraph 1 of Medical Treatment Law provides: “The hospital shall obtain the consent from the patient
or the patient’s spouse, relative or a related person who shall sign Consent to Surgical Operation and Consent to
Anesthesia before the surgical operation is conducted. Until the Consents are signed, the doctor shall explain to the
patient, or the patient’s spouse, relative or a related person, the reasons why the patient should receive the surgical
operation, the changes of success, and the possible complication(s) and risks of the surgical operation.