Академический Документы
Профессиональный Документы
Культура Документы
SPECIFIC NOTES RELATED TO PROCEDURE (if required) PRECISE ACTION POINTS UNDERSTOOD BY THE
PATIENT/SUBSTITUTE DECISION MAKER (to be documented
by patient/substitute decision maker)
Patient Identification Label
INFORMED CONSENT FOR PHYSIOTHERAPY
PATIENT’S AUTHORIZATION
The therapist has explained my medical condition and proposed procedure. I understand the risks of the procedure
including the risks that are specific to me, and the likely outcomes.
The therapist has explained other relevant treatment options and their associated risks.
The therapist has explained any significant risks and problems specific to me, and the likely outcomes if complications
occur. I have been given the choice to take a second opinion.
I was able to ask questions and raise concerns with the doctor the procedure and its risks, and my treatment options. My
questions and concerns have been discussed and answered to my satisfaction.
I understand that no guarantee has been made that the procedure will improve the condition.
It has been explained to me, that during the course of or subsequent to the Procedure, unforeseen conditions may be
revealed or encountered which may necessitate urgent medical attention or other procedures in addition to or different
from those contemplated. In such exigency, I further request and authorize the above named therapist or his designee to
perform such additional procedures as s/he or they consider necessary or desirable.
I understand that I have the right to refuse treatment or withdraw consent at any time. I agree that any such
refusal/withdrawal shall be in writing and acknowledged by the Hospital. And I shall be solely responsible for the outcome
of such refusal.
I declare that I have received and fully understood the information provided in this consent form, that I have been given
an opportunity to ask questions and raise concerns with the doctor about the procedure and its risks and my treatment
options. All my queries and concerns have been discussed and answered to my full satisfaction.