I, the undersigned, do hereby state and confirm as follows:

I have been explained the following in terms and language that I understand. I have been explained the following in {{LANGUAGE}} (Language) that is spoken and understood by me.
I have been provided with the requisite information; I have understood; and thereafter I consent, authorize and direct the above named doctor-in-charge and his / her team with associates or assistants of his / her choice to perform the proposed treatment mentioned herein above
I have been explained and have understood that due to unforeseen circumstances during the course of the proposed treatment something more or different than what has been originally planned and for which I am giving this consent may have to be performed or attempted. In all such eventualities, I authorize and give my consent to the medical team to perform such other and further acts that they may deem fit and proper using their professional judgment.
I have been explained and have understood the alternative methods and therapies of the proposed treatment, their respective benefits, material risks and disadvantages.
I state that the doctor-in-charge has answered all my questions to my satisfaction regarding the proposed treatment .
I have been explained and have understood that despite the best efforts there can be no assurance about the result of the proposed treatment. I further state and confirm that I have not been given any guarantee or warranty about the results of the proposed treatment.
I have been explained and have understood that despite all precautions complications may occur that may even result in death or serious disability.
I have been advised of the option to take a second opinion from another doctor regarding the proposed treatment.
I state that after explaining, counseling and disclosures I had been given enough time to take decision for giving consent.
I have signed this consent voluntarily out of my free will and without any kind of pressure or coercion.