I————————————————————————son / daughter / wife of ————————————————age —– years, resident of ——————————-being under the treatment of ————————————–(state here name of doctor / hospital / पंचकर्म centre ) do hereby give consent to the performance of medical treatment / पंचकर्म (including Poorvakarma and Pas`hchaatkarma ) —————————————— (mention Vamana, Virechana, Basti, Nasya, Raktamokshn`a, S`hodhana, S`hamana Chikitsaa etc.), being done from ——————- to ———————-, upon myself / upon ——————————————, age—————— who is related to me as ——————————————(mentioned here relationship, e.g. son, daughter, father, mother, wife etc.)
I declare that I am —— years of age.
I have been informed about the nature of my disease and treatment including पंचकर्म and the risks involved in the treatment. My questions about the treatment / पंचकर्म and the risks have been answered in asatisfactory manner. I have signed this consent voluntarily, out of my own free will, without any pressure and in my full senses, as I accept risk of likely harm, if any, in hope of obtaining the desired benefits from the treatment. The doctor has explained to me the following information which I have fully understood —
- Nature of my illness.
- Necessity and nature of treatment / Panchakarma.
- Effects, unwanted side effects, likely complications during and after पंचकर्म, including serious harm leading to death and my prognosis.
I allow the observing, photographing and televising of the procedure to be performed for medical, scientific, educational and research purpose and give my consent to publish the information in scientific journal, symposia without mentioning my name and am assured that the information gathered will be held in strict confidence.
I agree to co-operate fully with the doctor, to follow the instructions given to me from time to time. I will be fully responsible for the complications due to not following them.
Name and Signature of Witnesses Signature ofPatient / Guardian
- ———————————– ——————————-
Place: Signature of Doctor
Last updated on February 23rd, 2021 at 10:43 am