GARG HOSPITAL (AUNIT OF GARG HEART CENTRE & NURSING HOME (P) LTD.) 8-9, A.G.C.R. Enclave (opp. Karkardooma Court), Delhi - 110 092 h. : 43274444, Fax 43274455 AMBULANCE CONSENT FORM NAME... Slo, Dio, Wis..... IPD No.... VCODE NO. oes ‘Address with Contact No... Date... Time. INFORMED CONSENT (1) UMy Patient needs to be transferred fom. which an ambulance has beri requested by me. it has been explained to me in my language that journey may take, sminutes depending on trafic conditions. (A) 9/ a tht... a. Oe oe eat ee renin oR AT 7 ire ar ar ae seer GA Sere wT A a wer @, A arama wR we Pe oe 1 2. [have been told about the complications that may arise during this period. (2) wats ora Bahasa} ae read aka yl HET a aT 3. [understand that in the event of unexpected complications, | authorize the ambulance team to take appropriate steps in treatment. | further state that in the event of unexpected complications. myself or my family members will not hold any member of the ambulance team personally liable for penal action. Feet sera error oA RU AA tegen io wh OH wg ae EA AR a sree 1 2 wd, ae waren § Fe Fe rarer eve i Ra @ fhe 87 et Ron dda da wh Rieter aA aed at A wad Rime OY ag andere we 4, | agree to make full payment for the ambulance at the time of making a request for the same. (4) 8 dire Ho wee A pt pI oe a ee GET EI + (Siganture) 1. Name of the patient/patients guardianKelative : EMRIF/01/2009 2. Address... REV ODE 1/7/11