The Consent to Treat Form is a crucial medical-legal document required under Indonesian healthcare regulations, particularly for healthcare providers operating under Law No. 29 of 2004 on Medical Practice. This document is essential before conducting any medical procedure or treatment, except in emergency situations where immediate intervention is necessary to save life. The form serves multiple purposes: documenting informed consent, protecting patient rights, establishing the scope of authorized treatment, and providing legal protection for healthcare providers. It must be completed before any non-emergency medical treatment and requires thorough explanation of procedures, risks, and alternatives to patients in accordance with Indonesian medical practice standards and patient rights legislation.
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1. Patient Information: Complete details of the patient including name, date of birth, ID number (NIK), address, and contact information
2. Healthcare Provider Information: Details of the medical facility, treating physician(s), and relevant medical staff involved in care
3. Nature of Medical Treatment: Clear explanation of the proposed medical treatment, procedures, or examination
4. Risks and Benefits: Detailed explanation of potential risks, benefits, and expected outcomes of the proposed treatment
5. Alternative Treatments: Description of alternative treatment options and their respective risks and benefits
6. Right to Refuse Treatment: Statement of patient's right to refuse or withdraw consent at any time
7. Financial Responsibility: Statement regarding payment obligations and insurance coverage
8. Consent Declaration: Formal declaration of consent, including statements that information has been understood
9. Signatures: Signature blocks for patient/legal representative, witness, and healthcare provider
1. Emergency Contact Authorization: Additional section for authorizing emergency contacts to make decisions, used when patient wants to designate specific individuals
2. Interpreter Declaration: Section confirming that form contents were translated, used when patient requires language interpretation
3. Religious or Cultural Considerations: Special instructions regarding religious or cultural preferences affecting treatment, used when patient has specific cultural/religious requirements
4. Photography Consent: Permission for medical photography or recording, used when procedure may require documentation
5. Teaching Facility Disclosure: Acknowledgment of presence of medical students/trainees, used in teaching hospitals
6. Blood Product Refusal: Specific section for refusing blood products, used for patients with religious/personal objections to blood transfusions
1. Specific Procedure Details: Detailed technical information about specific procedures being consented to
2. Patient Rights and Responsibilities: Complete list of patient rights and responsibilities under Indonesian law
3. Hospital Policy Summary: Summary of relevant hospital policies affecting patient care and consent
4. Fee Schedule: Breakdown of potential costs and fees associated with treatment
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Patient Services
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Medical Records Manager
Clinic Manager
Healthcare Facility Director
Physician
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Admission Coordinator
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