Informed voluntary consent for medical intervention

I, _________________________________________________________________________________, ____________p.,

<I am the legal representative (mother, father, guardian, other ________________________) of a person under 15 years old / incapacitated: ______________________________________________________________________________>,

registered at: __________________________________________________________________________

in accordance with the requirements of Article No. 203 of the Federal Law “Fundamentals of the Protection of Citizens' Health in the Russian Federation”, I give informed voluntary consent to medical intervention at the Medical Center LLC “Old Quarters”

1. According to my will, I have been given full and comprehensive explanations of the nature, severity, probable prognosis and possible complications of my disease in a form accessible to me. I confirm that I understand the meaning of all terms.

2. I am familiar with the schedule and rules of the treatment and protection regime and undertake to comply with them.

3. I voluntarily give my consent to conduct diagnostic and therapeutic procedures for me included in the list of certain types of medical interventions, to which citizens give informed voluntary consent when choosing a doctor, namely: history taking; examination, including palpation, percussion, auscultation; anthropometric research; thermometry; tonometry; non-invasive studies of the organs of hearing, vision and ENT organs; the study of the functions of the nervous system; X-ray, ultrasound and endoscopic examinations; electrocardiography.

4. I agree with the proposed plan of medical measures (intracutaneous, subcutaneous, intramuscular and intravenous injections, intravenous fluids, external and local treatment, physiotherapy procedures).

5. I am informed about the objectives, nature, possible complications and adverse effects of diagnostic and therapeutic procedures, the possibility of not deliberately causing harm to health, as well as what I have to do during their implementation.

6. I am informed that I need to regularly take / use prescribed drugs and other methods of treatment, immediately report to the doctor about any deterioration in health, coordinate with the doctor taking any, not prescribed medications.

7. I am warned and aware that the refusal of diagnostic measures, treatment, failure to comply with the treatment and protection regime, recommendations of medical workers, treatment regimen, unauthorized use of medical instruments and equipment, self-treatment can complicate the treatment process and adversely affect health.

8. I informed the doctor about all health-related problems, including allergic reactions or individual intolerance to medications, all injuries, operations and diseases that I had, environmental and production factors affecting me, and medications. . I reported truthful information about heredity, as well as about the use of alcohol, narcotic and toxic drugs.

9. It is explained to me that I have the right to refuse one or several types of medical interventions included in the list, or to demand its (their) termination, except for the cases provided for by part 9 of article 20 No. 323-FZ Russian Federation".

10. I am informed of the intended results of medical care.

11. I agree to be examined by other medical professionals solely for medical, scientific or educational purposes, taking into account the preservation of medical confidentiality.

12. I am familiar with all the points of this document, had the opportunity to ask questions that interest me, and received answers to them in a form that I can understand.

I allow, if necessary, to report information about my state of health to the following citizens: ____________________________________________________________________________________

"_____" _____________________ 20__years.

A patient:____________________________________________

or his legal representative: _________________________

Medical worker: ________________________ (________________________)