<p style="margin-left:24px; margin-right:-6px"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">मी: .........................................................................&nbsp;</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">माझे&nbsp;</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">नातेवाईक: ..............................................................</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">यांचे उजव्या</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">/ </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">डाव्या</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">/ </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">दोन्ही डोळ्यांचे ऑपरेशन</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">, </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">डॉ</span></span>: ...........................................................<span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">यांच्या कडून</span></span> ,<span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">आवश्यक त्या गुंगीखाली </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">(</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">जनरल</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">/ </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">लोकल</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">/ </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">टॅापिकल</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">) </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">करण्यची</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">, </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">पूर्ण शुद्धीवर असतांना</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">, </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">स्व</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">इ</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">च्छेने परवानगी देत आहो</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">. </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">मला वरील शस्त्रक्रियेची माहिती</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">, </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">त्यातील धोके</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">, </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">लिमिटेशन</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">, </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">परिणामाबद्दल माहिती दिली आहे</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">. </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">शस्त्रक्रियेदरम्यान जंतूसंक्रमण</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">, </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">रक्तस्त्राव</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">, </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">अलर्जी</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">, </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">रिअक्शन इत्यादी संभावना</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">, </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">इतर संभाव्य दुष्परिणाम व त्यावरील उपाययोजना</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">, </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">माझ्या भाषेत मला समजावून सांगितले आहेत</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">. </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">वरील अडचणी उद्भवल्यास परीस्थितीप्रमाणे उपचार व शस्त्रक्रिया करण्याची परवानगी मी डॉक्टरांना देत</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">आहो</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">. </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">उच्च रक्तदाब</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">, </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">मधुमेह</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">, </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">हृदयरोग</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">, </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">लकवा</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">, </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">मूत्रपिंडविकार </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">,</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">इतर शारीरिक रोग </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">, </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">इत्यादीमुळे शस्त्रक्रियेदरम्यान किंवा नंतर काही संभाव्य दुष्परिणाम झाल्यास</span></span>,<span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif"> त्यावरील उपाययोजनेसाठी दुसऱ्या दवाखान्यात </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">ICU</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">मधे </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">(</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">अतिदक्षता विभागात</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">) </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">स्थलांतर</span></span>&nbsp; <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">व रुग्णाच्या खर्चाने उपचार करण्याची गरज भासू शकते हे मला सांगितले आहे</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">. </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">शस्त्रक्रियेशी निगडीत </span></span>/<span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif"> अनिगडीत किंव्हा योगायोगाने असे दुष्परिणाम उद्भवल्यास</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">त्याबद्दल माझी सदर रुग्णालय वा त्यातील कर्मचारी वृंदाबद्दल कोणतीही तक्रार नाही</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">. </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">हे संमतीपत्र मला पूर्ण समजले असून मला ते मान्य आहे</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">.</span></span></span></span></p>

<p style="margin-right:-6px"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">&nbsp; Anesthesia </span></span></p>

<p style="margin-left:24px; margin-right:-6px"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">रुग्ण कोऑपरेटीव्ह असल्यास डोळ्याचे</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">ऑपरेशन</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">केवळ</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">ड्रॉप </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">टाकुन करता</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">येते</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif"> (</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">म्हणजेच</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">टापिकॅल अनेस्थेसिया)</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">. </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">याचे</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">फार</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">कमी</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">धोके</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">असतात.</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">अन्यथा</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">, </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">डोळ्याच्या</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">बाजूला</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">एक</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">छोटे</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">इंजेक्शन</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">देऊन</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">ऑपरेशन</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">करता</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">येते</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif"> (</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">लोकल</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">/ </span></span>Local <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">अनेस्थेसिया</span></span>)<span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">. </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">यामधे</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">रक्तस्त्राव</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">होणे</span></span> (Retrobulbar hemorrhage)<span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">, </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">अलर्जी</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">, </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">रिअक्शन</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">येणे</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">, </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">डोळ्याला</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">सुईनी</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">इजा</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">होणे</span></span> (perforation)<span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">, </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">पापणी</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">थोडी</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">खाली</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">येणे</span></span> (Ptosis) <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">हे</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">व</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">काही</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">अन्य</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">धोके</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">संभवतात</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">. </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">साधारणतः</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">डो टला</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">पुर्ण</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">गुंगी</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">(</span></span>General Anesthesia) <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">देऊ</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">शकतात</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">.</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">मला</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">आणि</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">माझ्या</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">नातेवाईकांना हे</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">समजावले आहे</span></span>.<span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">ळ्याच्या ऑपरेशनला</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">पुर्ण</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">गुंगी</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">(</span></span>General Anesthesia) <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">लागत</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">नाही</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">. </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">पण</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">गुंगीच्या</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">डॉक्टरांना</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">ऑपरेशनमधे</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">गरज</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">भासल्यास</span></span> <span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">पेशं</span></span></span></span></p>

<p><span style="font-size:11.0pt"><span style="font-family:&quot;Calibri&quot;,sans-serif">Special Consents</span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">/ </span></span><span style="font-size:11.0pt"><span style="font-family:&quot;Calibri&quot;,sans-serif">Instructions </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">/ </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">विशेष सुचना </span></span><span style="font-size:10.0pt"><span style="font-family:&quot;Mangal&quot;,serif">-</span></span></p>