Name of Hospital
Doctor’s Unit Name
MEDICAL CONSENT FORM
1.
Name:
2. Age:
4. Email:
5. Mobile No:
7. UID
8. Date of admission:
3. Sex:
6. Address:
7. Date of discharge:
I, hereby give medical (general / specific) consent for my treatment under Dr............................. (Name of
doctor/s. The doctor/s has/have over ................ years of experience.
I have read and understood the enlisted information and the same has also been conveyed to me in my
own language and all my doubts have been cleared up.
1. I understand that my treating doctor/s .............................is/are honorary consultant/s and not hospital
employee/s.
2. Being honorary consultants, they provide consultation to their patients and visit the hospital twice in a day,
morning and evening. I understand that they are on call for SOS consults.
3. During their absence, the hospital provides cover through residents/floor doctors, who are on the payroll of
the hospital.
4. During emergencies, the hospital provides resident/Intensivist cover. Intensivists are doctors who
specialize in the care of critically ill patients. They may shift the patient, if need arises, to the intensive care
unit (ICU) and are authorized to act independently as per the need of the situation.
5. The night cover is provided by the hospital resident/floor doctors. The treating doctors are available on
phone in the night, but for any emergency it is the hospital that provides the intensive care coverage to
tackle any unforeseen event. The hospital will charge separately for these facilities.
6. I understand that there may be situations when the treating consultant/s may not be able to reach the
hospital in time in an emergency. In such a situation, the hospital ICU will provide necessary cover and
take appropriate need-based decisions.
7. I understand that nursing care is provided by the hospital and is not under the direct control of honorary
treating consultants.
8. If I have any problem with the nursing care, I/my relatives need to contact the floor nursing manager for the
same.
9. I understand that Dietary services are provided by the hospital through a hospital dietician who can be
approached through the nursing staff. Treating doctors do not directly control the dietary services.
10. I have been told that doctors do not guarantee a cure. They only provide treatment and carry out
investigations to the best of their knowledge, skills, acumen and experience.
11. I understand that a situation may arise where even after days of hospital admission, my treating doctors
may not be able to reach a diagnosis. In such situation, I hereby authorize my primary treating doctor/s to
call upon other specialist/s for a second opinion. The fee for the specialist/s will be charged separately.
12. I understand that my treating doctor/s has/have no objection to discuss my case with my primary referral
doctor or family physician.
13. I hereby authorize my treating doctor/s to investigate me to the best of their skill and knowledge and what is
in my best interest.
14. I understand that there is a theoretical high risk of sudden cardiac arrest in patients with uncontrolled blood
pressure, uncontrolled diabetes, unstable heart blockages, morbid obesity, abnormal lipids, acute febrile
illness (dengue, pneumonia,) etc. Sometimes, the patient may develop cardiac arrest due to lung clots
(pulmonary embolism) in the ward, which may be life- threatening. This usually occurs when the patient has
been bed ridden for some time.
15. I understand that it is my responsibility to tell the doctors each day if I have not passed motion/flatus after
24 hours of hospital stay or if I have not passed urine in less than 8 hours on any day.
16. I understand that in spite of the best care by the hospital, there may be an accident such as fall from the
bed. To prevent such an event, I am supposed to keep an attendant with me at all times, except in the
intensive care areas.
17. I hereby give permission and authority to my treating doctors for certain invasive procedures like fluid
aspiration, dressing, internal cavity fluid aspirations, etc. Each one of these procedures may have some
inherent complication rate, including a rare mortality.
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18. I understand that even administration of intravenous (IV) fluids is not without any risk. There are chances of
developing inflammation, infection, drip reaction (fever and chills), oozing of blood, and swelling from the IV
site.
19. I hereby also give consent for any radiological investigation/s, which may include ultrasound, CT scan,
MRI, etc. I understand that any x-ray or CT imaging involves radiation risk.
20. I hereby authorize my treating doctor/s to go ahead with necessary investigations irrespective of the cost in
the best interest of my condition.
21. I have been explained about the hospital charges, including the policy of advance payment and will abide
by the same.
22. I understand that a situation may arise where I may need a blood transfusion. I hereby authorize my
treating doctors to arrange necessary blood from voluntary donors for transfusion. The hospital may ask
me to arrange for a replacement blood donor.
23. I understand that the Blood Bank is a hospital department and the blood is issued by them and transfused
by the nurses under the supervision of the hospital resident/floor doctor/s. The role of the treating
consultant/s is only to decide whether a transfusion is required or not. If any blood transfusion reaction
occurs, it is the responsibility of the hospital and not the treating doctors.
24. I understand that it is my duty to disclose on oath all my previous illnesses at the time of admission. Any
false information added to Mediclaim may amount to a fraud.
25. I have declared my history of any drug allergy, history of past illnesses and personal history including my
habits and addiction/s at the time of admission and same cannot be changed unless provided by proofs.
26. I have checked the spelling of my name, age and address at the time of admission as it may be difficult to
change these parameters at the time of discharge or after discharge from the hospital.
27. Certain medical procedures may be sometimes necessary in the course of medical treatment and include
putting in a Ryle’s tube, urinary catheter, etc. I hereby give consent for the same.
28. I understand that nothing comes free in a corporate hospital. I have to pay for all consumables, which may
include gloves, hand sanitizer, tissue paper, soaps, thermometer, etc. I have the right to carry these
disposables home, which have been issued/billed to me, after discharge from the hospital.
29. Many of the consumables may not be covered by the Mediclaim policy/Public sector
undertaking/Government units. For these, I may be billed separately and may have to pay cash. It is my
duty at the time of admission to clarify with the admission office the items that are not reimbursable.
30. I understand that the hospital does not accept cheques and I have to pay the final bill either in cash or
through demand draft.
31. I understand that if I pay by credit card, the charges may be extra.
32. I understand that being a corporate institution, there are no provisions for concessions. The treating
doctor/s should not be embarrassed by asking them for the same as they may have no role in this.
33. I understand that hospital charges more money for inpatients for certain investigations/procedures
compared to outpatients.
34. I understand that the hospital does not allow any outside food to be brought in the hospital.
35. I understand that the hospital policy does not allow children to visit the hospital.
36. I understand that there are strict visiting hours, which my relatives might have to abide with.
37. I understand that hospital does not allow flowers to be brought within the hospital premises.
38. I understand that hospital is a smoking-free zone.
39. I understand that hospital will provide vegetarian healthy diet.
40. I understand that the hospital may not permit me to buy medicines or procure devices from a pharmacy
outside the hospital.
41. I understand there is a separate counter in the hospital to assist for Mediclaim or PSU formalities. It is my
duty or my relatives’ duty to get Mediclaim form issued from the counter and get it signed by the treating
consultant and then fax it to the TPA. It will be my duty (not my treating consultants) to follow it up with the
TPA through the TPA desk. The TPA form needs to be submitted within 24 hours of admission. If there is a
delay, the primary doctors will not be responsible for the same.
42. I understand that on the day of discharge it may take 6-8 hours by the Mediclaim counter or the TPA to
process my queries and finally sanction the claim.
43. I understand that if I leave the hospital in the night, my Mediclaim policy may be cancelled.
44. For any ward leave, I need to contact the treating doctor/floor doctor/floor manager/floor nursing staff and
also provide the reasons for the request.
45. I understand that the Mediclaim insurance will cover only 1% of my insured amount as the room rent (2/%
for intensive care). If I upgrade my room, my charges will also increase for other services too; but, the
insurance company may reimburse me for my room/other services as per original entitlement.
46. I understand that the hospital charges may differ for different categories of patients. It is not like a hotel
where the difference is only in the room rent. The charges of surgery, anesthesia, doctor’s fee, etc. may
vary as per the bed category chosen by me.
47. I understand that at the time of admission, the doctor/s may admit me with a provisional diagnosis (disorder
A) and may reach a different diagnosis (disorder B), for which investigations and treatment facilities may
not be available in the hospital. In such a situation, the hospital may ask me to transfer to another hospital.
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48. I understand that the hospital may not have all the facilities that are available in the world.
49. In case of sudden cardiac arrest in the hospital premises, the hospital policy is to call a ‘Code Blue’ in
which hospital intensive care team reaches the spot and provides resuscitative measures. Resuscitation
may be done in the room or the patient may be shifted to the ICU. The primary treating doctor/s may or
may not be present during this emergency. Certain life-threatening emergency procedures like
tracheostomy may need to be carried out at that moment.
50. I understand that certain unforeseen accidents may occur in the hospital premises in spite of the
precautions. These may include burn while taking steam, ECG electrode burn, electric monitor burn, fall
from the bed, etc.
51. I understand that it is my responsibility to disclose any drug allergy at the time of admission. I also
understand that there may still be some drugs to which I may be allergic and may cause a drug reaction.
Every unforeseen drug reaction carries a theoretical risk of morbidity and mortality.
52. I am/am not suffering from HIV, Hepatitis B and/or C.
53. I am/am not suffering from open Tuberculosis.
54. I understand that I need to declare if I have been treated by a quack in the recent past.
55. I understand I need to disclose if I am on Ayurvedic, Homeopathic, Unani or drugs from other traditional
healers.
56. I have disclosed my smoking status: □ Smoker □ Non-smoker
57. I have disclosed my alcohol intake: □ Yes
□ No
58. I do understand that smokers may carry high mortality and morbidity when treated and their response to
treatment may be poor.
59. It is my duty to disclose my past vaccination status. I have been explained and understood the suggestions
for my future vaccinations.
60. I understand that the hospital has a policy to examine any female patient in the presence of a female
attendant or in the presence of the husband/father.
61. While doing an ECG, X-ray or Echocardiogram, it may be possible that these may be done by a male
technician or a male doctor in the presence of a female attendant. I hereby give my permission for the
same.
62. I understand that when I come for a check-up, there is an implied consent for physical and clinical
examination, which may involve examination of all parts of the body, if clinically indicated
63. I understand that there are chances of acquiring new infection in the hospital premises by me or my
relatives/friends visiting me. Getting hospital-acquired infection/s in spite of precautions may not mean a
medical negligence on the part of the treating doctors.
64. Even after taking all the care, it is still possible to develop bed sore/s during the hospital stay depending
upon my nutritional status and immunity.
65. I understand that ward boys and safai karamcharis may not be available in the ward all the time. These
services are provided by the hospital and not by treating consultant/s. In case there is any delay in any
such services, I need to contact the floor manager to sort out the same.
66. I understand that my primary treating consultant/s will see me twice a day. They are allowed to see me
once more, if the need arises, for which my treating doctor/s will be entitled for one more consultation. My
treating doctors, therefore, are allowed two routine and one extra emergency consultation in a day. On the
day of admission and on the day of discharge, two consultations may be charged. Even a telephonic
emergency consultation at odd hours is counted as a valid emergency visit as it involves change in medical
treatment.
67. I understand that there is no ‘Do Not Resuscitate (DNR)’ policy in India. It is my duty to follow the legal
obligations regarding end of life issues.
68. I understand that it is my right to get a refund of unused medicines and disposables at the time of
discharge.
69. I understand that difference of opinion and error of judgment is not negligence.
70. I understand that deviation from normal practice is not negligence.
71. I understand that medical accidents are known to occur and do not amount to negligence.
72. I understand that to err is human.
73. I understand that I have the right to choose my consultant/s.
74. I understand that at the time of discharge I will be given a copy of the detailed discharge summary for my
future records.
75. At the time of discharge I will be given radiological films, ECGs etc. However, I understand that in
medicolegal cases, these may be the property of the hospital for legal purposes.
76. In an unforeseen event like death, I give/do not give permission to the hospital to initiate the process of an
autopsy.
77. I understand that the honorary treating doctors bill their professional fee through the hospital and the same
is clearly reflected in the bill. This fee also includes hospital service charges for providing infrastructure for
admitting the patients. All other charges are billed by the hospital and belong to the hospital. There is no
system in which the primary treating consultant gets any cut or commission for admitting their patients in
the hospital. Billing is transparent and fee charged by the doctor/s is transparently reflected in the bill.
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78. The hospital may get certain investigations, not available in the hospital, from empanelled diagnostic
centres. Billing for the same is done by the hospital. For these services hospital charges may include some
extra service charges.
79. For drugs and devices not available in the hospital, procuring them from outside the hospital may include
some extra service charges.
80. It may be possible that the hospital may provide devices/implants at a higher costs than their purchase
price as the Indian Government does not have an MRP on these items. The hospital may charge more to
cover the cost of expiry, inventory, accidental fall, etc. The treating consultant does not get any money out
of these.
81. I have been made to understand that Mediclaim does not mean 100% cashless facility. Ten percent of
cases may be denied and asked to pay the bill and get reimbursment later.
82. I understand that Delhi Medical Council does not allow doctors to provide a medical certificate for more
than 15 days without a medical reason. The hospital may charge money for issuing a certificate and the
certificate is not valid without the counter signature of the medical administrator and the patient.
83. I understand that at the time of death the hospital has provisions for cold mortuary on chargeable basis.
84. I have been made to understand about the following;
a. Provisional diagnosis
b. Expected duration of stay
c. Expected approximate hospital bill (the bill may increase if the hospital diagnosis changes)
d. Possible complications.
e. Waiting time for my reports
85. In an unforeseen situation like death, the hospital may ask to clear the bill before the death certificate is
released.
86. At any stage, if I am dissatisfied with services of the hospital I need to inform the treating doctor/s and
administration at that point in time and not at the time of settling the bill.
87. I understand the hospital bill does not cover the follow up visits for which I may be billed separately.
88. Hospital bills are computerized and may have computer errors. It is my duty to cross check the bill at the
time of payment and get it sorted out with the billing department.
89. It is my duty to sign the bill and the discharge tickets at the time of discharge.
90. I may be asked to sign separate specific consents form/s in addition, for example, for any surgical
procedure.
91. I understand that I am allowed to call my family doctor to discuss the case with the treating doctors after
permission.
92. If I need a private nurse, I need to ask the hospital to arrange for a private nurse.
93. If I need an ambulance, I need to ask the hospital to arrange for an ambulance.
94. I understand that split ACs are a greater source of infections than window ACs.
95. I understand that cross infections may occur in ICUs.
96. I understand that I may be billed for disposable sheets, disposable gowns, disposable gloves etc.
97. I understand that the hospital follows a privacy policy and any information given by me is not disclosed to
any other person without my permission.
98. In an unforeseen situation, if I end up unconscious, paralyzed or if I am not in a position to give a consent
or specific consent or statement I hereby authorize …………………… to give consent and take all medical
decisions on my behalf.
99. I hereby authorize …………………… to be briefed about me in routine/emergency situation.
100.
I have declared my past medical history: diabetes (…… years), hypertension (…. years), asthma
(….. years), abnormal lipid (….. years), COPD (….. years), cancer (….. years), heart blockages (…..
years), paralysis (….. years), depression (….. years), acidity (….. years), any other ……………………..
Signature of Patient:
Signature of Spouse:
Signature of Others:
Signature of Consultant(s):
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