Patient Consent Form

Ensure informed and documented patient consent before any medical procedure to maintain transparency, trust, and legal protection.

CESAREAN SECTION (C-SECTION)

Patient Information

Name:

Age:

UHID:

Indication:

Procedure

Cesarean Section (Surgical delivery of baby)

Doctor Information

Surgeon:

Assistant:

Anesthetist:

Risks & Complications

  • Bleeding / transfusion
  • Infection
  • Injury to bladder/bowel
  • Anesthesia complications
  • Blood clots
  • Delayed wound healing
  • Future pregnancy complications (scar uterus)
  • Risk to baby (breathing issues, NICU admission)
  • Rare risk of death

Special Consent

Consent

I understand risks to both mother and baby

Patient Signature:

Date:

Doctor Signature:

Date:

Witness Signature:

Date:

Hospital Seal

OBSTETRIC / GYNECOLOGICAL SONOGRAPHY (ULTRASOUND)

Patient Information

Name:

Age:

UHID:

Type of Sonography

Doctor Information

Referring Doctor:

Referring Doctor:

Procedure Explanation

Ultrasound is a diagnostic test using sound waves. In TVS, a probe is gently inserted into the vagina for better imaging.

Important Information

  • This is a diagnostic test and may not detect all abnormalities
  • Findings depend on clinical condition/pregnancy stage
  • Further tests may be required

Risks / Discomforts

  • Mild discomfort (especially TVS)
  • Rare risk of infection
  • No radiation risk

Legal Declaration (PCPNDT Act)

I understand that disclosure of fetal sex is strictly prohibited and I will not request it.

Patient Signature:

Date:

Doctor Signature:

Date:

Witness Signature:

Date:

Hospital Seal

MEDICAL TERMINATION OF PREGNANCY (MTP)

Patient Information

Name:

Age:

UHID:

Diagnosis / Indication:

Procedure

Medical / Surgical Termination of Pregnancy (as per clinical indication)

Doctor Information

Registered Medical Practitioner:

Assistant (if any):

Explanation of Procedure

The doctor has explained:
  • The reason for termination
  • Available methods (medical pills / surgical procedure)
  • Expected outcomes and follow-up requirements
Risks & Complications
  • Bleeding (may require transfusion in rare cases)
  • Infection
  • Incomplete abortion (may require further procedure)
  • Failure of procedure (continuation of pregnancy)
  • Abdominal pain / cramps
  • Injury to uterus (in surgical method)
  • Anesthesia-related risks (if applicable)

Legal Declaration

I confirm that:
  • I am undergoing this procedure voluntarily
  • I understand that the procedure will be carried out as per the MTP Act
  • My confidentiality will be maintained

Consent

I have understood the procedure, risks, benefits, and alternatives, and I give my informed consent.

Patient Signature:

Date:

Doctor Signature:

Date:

Witness Signature:

Date:

Hospital Seal

Guardian Name & Signature:

(For minor / guardian consent if applicable)