Chart No.
Name
Unit
(Patient Imprint Card)
Facility:
1.
.
.
.
2. .
3. (
)
)
. (
__________________________________________________________ _____________________ ______________)
am (
() () / () )and(
)pm(
(Signature of Patient or Parent/Legal Guardian of Minor Patient) Date)
( (Time)
If the patient cann
ot consent for him/herself, the signature of either the health care agent or legal guardian who is acting on behalf of
the patient, or the patient’s surrogate who is consenting to the treatment for the patient, must be obtained.
______________________________________________________________________________ ______________)
am (
() / () )and(
)pm(
(Signature of Health Care Agent/Legal Guardian) (Date) (Time)
(Place a copy of the authorizing document in the medical record)
______________________________________________________________________________ ______________)
am (
() )and(
)pm(
(Signature and Relation of Surrogate) (Date) (Time)
(GENERAL CONSENT FOR
TREATMENT)
FORM A
/ /
/
For patients seeking in-patient, out-patient and/or emergency room services.
) WITNESS :(
I, __________________________________________________________am a staff member who is not the patient’s physician
or authorized health care provider and I have witnessed the patient or other appropriate person voluntarily sign this form.
__________________________________________________________________________ _____________ )
am (
)Signature and Title of Witness:( )and(
)pm(
)Date( )Time(
/ )INTERPRETER/TRANSLATOR:(
(To be signed by the interpreter/translator if the patient required such assistance)
To the best of my knowledge the patient understood what was interpreted/translated and voluntarily signed this form.
___________________________________________________________________________ _____________ )
am (
/ )Signature of Interpreter/Translator( )and(
)pm(
)Date( )Time(
HHC 100A (R Mar 2016) Arabic
