| FORM OF CONSENT FOR EXAMINATION AND TREATMENT |
| Private Hospital ..................................................................................... |
| Name Of Patient ....................................................................................... |
| (For patient who is competent to sign) |
| I ....................................................................................... hereby consent to and |
| Name of Medical Practitioner |
| authorise .................................................................. to perform such examination and treatment (including operation and anaesthetic) as in their opinion may be advisable. |
| Nature of examination or treatment ......................................................... I hereby acknowledge that the nature of the proposed examination and treatments (including operation and anaesthetic) had been explained to me, and I acknowledge that no guarantee or assurance has been made as to the results that may be obtained. |
| ....................................................... | ........................................................ |
| Witness not related to patient | Patient |
| Date ....................................... |
| (For patient who is a minor unable to sign for medical reason, this consent should be signed by the guardian or the nearest relative of full age). |
| ............................................ |
| Responsible person |
| ............................................ |
| Relation to patient |
| ................................................... | Date ............................................... |
| Witness not related to patient. |
| (In the case where the patient or responsible person does not understand English the foregoing consent has been carefully interpreted to him or her). |
| ................................................ |
| Witness not related to patient |
| .......................................... |
| Date .................................... |