@if($data->ConsentType == 1) @else @endif
Sanjeevan Hospital
Rathi Nagar, Amravati - 444603
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GUARDED VISUAL PROGNOSIS CONSENT
HIGH RISK CONSENT
Name :  {{$data->txtptname}} MRD No :  {{$data->txtmrdno}} Age / Gender :  {{$data->txtage}}
Proposed Treatment / Surgery  {{$data->txtsurgerytreatment}}
Diagnosis :  {{$data->txtdiagnosis}}
Investigations / Diagnostic Test Performed :  {{$data->txtinvestigation}}
Fitness for treatment / Surgery given by :  {{$data->txtfitness}}
Prognosis / Possible Complication / Nature of Risk :  {{$data->txtprognosis}}
I have been explained the above details and terms in the language {{$data->Language}} that i understand.
I state the Doctor has answered all my questions to my satisfaction regarding the proposed treatment / surgery and any alternative modes of treatment.
I have been explained and understand that despite the best efforts there can be no assurance about the result of proposed treatment / surgery
I further state & confirm that I have not been given any guarantee or warranty about the result of proposed treatment / surgery
I have beed explained and have understood that despite all precautions, complications may even result in death or serious disability / loss of vision of eye.
I have signed this consent voluntarily out of my free will and without any kind of pressure or coercion.
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Signature / Thumb Impression of Patient (Parent in case of Minor) Date & Time : {{date("d/m/Y", strtotime(str_replace('-', '/',$data->dtentrydate)))}} - {{date("h:i a", strtotime(str_replace('-', '/',$data->dtentrytime)))}}
Name of Patient : {{$data->txtptname}} Place : {{$data->txtplace}}
 
Signature / Thumb Impression of Witness Signature / Thumb Impression of Witness 2
Name of Witness : {{$data->txtwitness1}} Name of Witness2 : {{$data->txtwitness2}}
Relation {{$data->txtrelationship1}} Contact {{$data->txtcontactno1}} Relation {{$data->txtrelationship2}} Contact {{$data->txtcontactno2}}
 
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient.
I have given an opportunity to ask questions and i have answered these.
 
Doctor's Signature Date & Time : {{date("d/m/Y", strtotime(str_replace('-', '/',$data->dtentrydate)))}} - {{date("h:i a", strtotime(str_replace('-', '/',$data->dtentrytime)))}}
Doctor's Name : {{$drname}} Place : {{$data->txtplace}}