Table 4.

Additional informed consent form for gastrointestinal endoscopy in the coronavirus disease-2019 era

Hospital name Date
Patient details
Name of consultant
Name of procedure
I,………………………………………………………….…………S/o ………………………………………from………………………………………………..
Here by give my consent for the procedure:…………………………………………………………………. Type of anaesthesia:…………………………… performed by Dr…………………………………………… on ……………………………… at……………………………….………………………..hospital
I understand that in this period of COVID-19 pandemic, I have come to the hospital voluntarily for my emergency treatment
I understand that I could already be an asymptomatic carrier or infected by COVID-19 carrier, now without any manifestation of disease
I understand that all efforts are taken by the hospital and its staffs at all levels to prevent any cross infection to me
I also understand that the morbidity or complications related to procedure are higher in COVID-19-infected patients
I understand and fully agree that hospital/HCP won’t be held responsible for any COVID-19 Infection acquired by me or any of accompanying people during my hospital stay or later
The incremental costs in the COVID-19 era have been explained to me and agree to the same
I have fully understood all the above-mentioned details, clearly explained to me by the doctor in my mother tongue. Hence, I fully agree and give this signed consent for the above mentioned procedure voluntarily

HCP: Healthcare personnel, COVID: Coronavirus disease