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CT Scan Request 2nd Page

This document provides an informed consent form for patients undergoing CT scans, CT-guided biopsies, anesthesia, contrast administration, or other procedures at Balanga Medical Center. It outlines that the patient or their legal representative consents to the named examination or procedure being performed. It also states that the risks and alternative procedures have been explained by the doctor. The patient consents to blood transfusions if needed and anesthesia administration. Any biopsied tissues may be used for standard hospital procedures. The patient certifies they understand the consent and that no guarantees were made by medical staff regarding results.

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Aina Haravata
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254 views1 page

CT Scan Request 2nd Page

This document provides an informed consent form for patients undergoing CT scans, CT-guided biopsies, anesthesia, contrast administration, or other procedures at Balanga Medical Center. It outlines that the patient or their legal representative consents to the named examination or procedure being performed. It also states that the risks and alternative procedures have been explained by the doctor. The patient consents to blood transfusions if needed and anesthesia administration. Any biopsied tissues may be used for standard hospital procedures. The patient certifies they understand the consent and that no guarantees were made by medical staff regarding results.

Uploaded by

Aina Haravata
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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INFORMED CONSENT FOR CT SCAN EXAMINATION, CT-GUIDED BIOPSY, ANESTHESIA, CONTRAST

ADMINISTRATION OR OTHER PROCEDURES

TO WHOM IT MAY CONCERN:

For Capacitated Patient:

I, the undersigned, _______________________________________, a patient of Balanga Medical Center, of legal age and with residence and
postal address at ______________________________________________________ hereby consent to the performance of
_____________________________________________________ on me.

Or For Incapacitated Patient (minor, unconscious or demented):

I, the undersigned, ________________________________________, of legal age and with residence and postal address at
_______________________________________________________________________________ hereby consent to the performance of
______________________________________________________ on my ____________________, _______________________________, a
patient of Balanga Medical Center Corporation. l (Relation) (Name of Patient) lll

Examination / Procedure / Operation / Anesthesia

I hereby authorize Dr. /s ___________________________________________________________________________ and whomever he/she may


designate as his/her assistant/s or representative/s to perform the said examination/procedure.

I acknowledge that Dr. /s __________________________________________________________________________ has/have fully explained to


me in simple, sufficient and understandable language including the risks involved and/or their alternative procedures and the risks involved or
potential consequences or complications and have answered all questions I have asked about in top satisfaction.

Should my physical determine during my examination or immediate post-procedure period that a transfusion of blood and/or body product is
necessary, I consent to the administration of those blood and/or blood products. Although it is unlikely, transfusions of blood products may
transmit diseases such as Hepatitis or AIDS. I authorize the above named doctor/s and his/her assistants to perform such transfusions as are
necessary and desirable in the exercise of professional judgment.

I further consent to the administration of anesthesia which may be considered and deemed proper for whatever procedures that may be done on
me.

Any tissue/organ/body part surgically removed on biopsy in accordance with the standard procedures of the hospital.

I hereby certify that I have read and fully understood the above stated consent for CT scan examination, CT-guided biopsy, anesthesia, contrast
administration or other procedures, that the explanations referred to therein have been made, and that all blanks requiring insertion or completion
were filled in before I signed. I also certify that no guarantee on the result of the examination has been made, expressly or implicitly by the
medical staff involved.

IN WITNESS WHEREOF, I hereby affix my signature/right “thumb mark” below.

_______________________________________________
______________________________ Signature over printed name of patient or person giving
Date and Time lllll l free consent or his/her right “thumb mark”)

EXPLAINED AND SIGNED IN THE PRESENCE OF:

_______________________________________________
______________________________ l Signature over Printed Name explained by MD
Date and Time

______________________________________________
______________________________ l ccc Witness
Date and Time

________________________________________
______________________________ l l Witness
Date and Time

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