PATIENT CONSENT FORM — DRAFT FOR ATTORNEY AND CLINICAL REVIEW Form Ref: PCF-2026-001 Date of Preparation: June 1 2026 INTERNAL REVIEW NOTE: This is a structured preparation draft only. It must be reviewed and finalized by a qualified healthcare compliance attorney and the relevant clinical team before it is presented to any patient. Apollo Multispecialty Hospital Department of General Surgery Mumbai Maharashtra India Patient Services: 022-2626-2626 1. INTRODUCTION AND PURPOSE Welcome. We want to make sure you fully understand the procedure being recommended for you before you decide whether to proceed. This form is part of a conversation between you and your healthcare team — not a replacement for that conversation. Please read it carefully, ask any questions you have, and know that your healthcare team is here to help you understand everything before you make your decision. Signing this form means you have had the chance to discuss the procedure and your questions with your doctor. 2. ABOUT THIS CONSENT PROCESS Informed consent is a process of open communication between you and your healthcare team. It means you receive clear information about the procedure being recommended, you understand that information, you have the chance to ask questions, and then you make a free and voluntary choice about whether to proceed. You always have the right to say no or to change your mind at any time. Doing so will never affect the quality of care you receive for your other health needs. 3. DESCRIPTION OF THE PROCEDURE The procedure being recommended for you is a laparoscopic appendectomy, which is a minimally invasive surgery to remove your appendix through small incisions in the abdomen using a tiny camera and surgical instruments. Before the procedure you will be prepared by the nursing team, an intravenous line will be placed, and you will be given a general anesthetic so you are fully asleep during the surgery. The procedure typically takes approximately 30 to 60 minutes. Afterward you will be monitored in a recovery area as the anesthetic wears off and you will be given guidance on your recovery before you leave the hospital. CLINICAL REVIEW NOTE: The specific details of how this procedure will be performed in your individual case will be discussed by your surgeon. The clinical accuracy of all descriptions in this section must be verified and finalized by the surgical team before this form is used. 4. PURPOSE AND INTENDED BENEFITS This procedure is recommended to remove your appendix, which has become inflamed and infected. The goal is to relieve the pain and infection you are experiencing and to prevent the appendix from rupturing, which could cause a more serious infection in the abdomen. Individual results vary and the healthcare team cannot guarantee any particular outcome. Your surgeon will discuss the expected benefits specific to your individual situation. This procedure is recommended as medically necessary based on your current clinical presentation. The clinical characterization of this procedure in your individual case must be confirmed by your treating surgeon. 5. RISKS AND POTENTIAL COMPLICATIONS General risks associated with this type of procedure include: 1. Bleeding during or after the procedure, which may in some cases require additional treatment. 2. Infection at the incision sites or within the abdomen, which is treated with antibiotics. 3. Risks associated with general anesthesia, which will be discussed separately with you by the anesthesia team. 4. Injury to nearby structures such as the bowel or blood vessels, which may require additional surgical repair. Rare but more serious risks include conversion to open surgery if the laparoscopic approach cannot be safely completed, and rare but serious anesthesia complications. These serious risks are uncommon and the surgical team takes active steps to minimize them. Please ask your surgeon any questions you have about these risks before deciding to proceed. CLINICAL REVIEW NOTE: The clinical accuracy of this section must be reviewed and finalized by the surgical team before this form is used with any patient. 6. ALTERNATIVES AND CONSEQUENCES OF DECLINING Alternatives to laparoscopic appendectomy include: 1. Open appendectomy: A larger incision is made in the abdomen to remove the appendix. This may be recommended if laparoscopic surgery is not suitable for your situation. 2. Antibiotic treatment: In some cases antibiotics alone may be considered. Your surgeon will advise whether this is appropriate for your situation. 3. Watchful waiting: In some limited circumstances a wait-and-observe approach may be discussed. This carries risks of the appendix rupturing. 4. No treatment: You have the right to decline any treatment. However, untreated appendicitis carries serious risks including rupture and life-threatening infection. Choosing an alternative or declining this procedure is always your right and will never affect the quality of care you receive for your other health needs. 7. ANESTHESIA AND STUDENT INVOLVEMENT This procedure requires general anesthesia. You will be fully asleep and will not feel pain during the surgery. The anesthesia team will discuss the specific risks of anesthesia with you separately, and a separate anesthesia consent form may be required. Apollo Multispecialty Hospital is a teaching hospital. Medical students, junior doctors, or other trainees may be present during your procedure in an observing capacity to support their medical education. Your treating surgeon will remain responsible for your care at all times. If you prefer that no students or trainees be present during your procedure, please let your healthcare team know and your preference will be respected. Please indicate your preference: I consent to the presence of medical students or trainees during my procedure: Yes ___ No ___ 8. PATIENT RIGHTS AND PRIVACY Your health information collected in connection with this procedure will be protected in accordance with applicable Indian health privacy law and hospital policy. You may request a copy of the hospital's privacy notice from the patient services team on 022-2626-2626. Your rights in this consent process include: - The right to receive honest and complete information in language you understand - The right to ask questions and receive clear answers before deciding - The right to take time to consider your decision - The right to decline or withdraw consent at any time without penalty - The right to have a support person present during the consent discussion - The right to receive a copy of this signed form - The right to request an interpreter or communication support if needed 9. VOLUNTARY DECISION AND REVOCATION Your decision about this procedure is entirely your own. You have not been pressured into any decision and declining will never affect the quality of care you receive for your other health needs. You may change your mind and withdraw your consent at any time before the procedure begins. Once a surgical procedure has begun, stopping may not be possible for your safety. Please discuss any concerns with your surgeon before the procedure starts. Patient Questions and Notes: __________________________________ __________________________________ I confirm that my doctor has explained this procedure to me, answered my questions, and that I feel I have enough information to make my decision. 10. SIGNATURE BLOCKS PATIENT CONSENT: I have read this form, had the opportunity to ask questions, understand the information provided, and voluntarily agree to proceed with the laparoscopic appendectomy described above. Patient Name (print): __________________ Patient Signature: _____________________ Date: ____________ Time: ______________ Any limitations on my consent: __________ REPRESENTATIVE CONSENT (if applicable): Full Name: ____________________________ Relationship to Patient: _______________ Legal Authority: ______________________ Signature: ____________________________ Date: ________________________________ HEALTHCARE PROVIDER CONFIRMATION: I confirm that I have discussed this procedure with the patient, answered their questions, and believe they understood and voluntarily agreed to proceed. Provider Name (print): _________________ Signature: ____________________________ Professional Title: ____________________ Date: ________________________________ DISCLAIMER: This Patient Consent Form draft was generated by an AI drafting tool as a structured preparation and documentation aid only. It does not constitute a certified legally valid consent form and must not be used with any patient without review and finalization by a qualified healthcare compliance attorney and the relevant clinical team.