CONSENT FORM FOR VENTILATION AND ICU

PROCEDURES

I ________________________ , S/O W/O D/O B/O G/O

___________________________ do hereby give my
consent for intubation and mechanical ventilation
of my patient. The doctor I/C has duly explained
me all the risks and benefits involved. I am fully
aware that my patient is critical and requires
intensive care and support. I am ready to keep
him/her at CH KALLA and have refused to take him
outside on emergency referral basis. I am also fully
aware regarding the cost that may be incurred on
my patient. I have explained about the drugs that
may not be re-imbursed as per company
provisions. In case of any event of mortality, whole
responsibility shall be mine and the CH KALLA
Admin,Doctor I/C and Nursing staff shall not be
held responsible. I will also take care not to go
inside CDIC/8 more than required and without
permission and shall also prevent my family
members to flock inside.

Signature /Relation