CONSENT FORM OCULUS HEALTHCARE Pvt.

Ltd 1ST Floor, Mahaluxmi Metro Tower, Sector-4, Vaishali, Ghaziabad-201010 Authorization for Medical And /OR Surgical Treatment

No. Date.. I ,Name ...Age. Gender.. S/o W/o D/o. R/O. ..Tel ephone/MobileNo .. The Undersigned hereby authorize Dr.Manju Jain Verma/Dr. Ruma Gupta and /or whomsowever he/she Designate as his/her assistant s/Colleagues to administer such treatment as necessary and to perform the following operation procedure and such additional operation of procedure as are considered therapeutically necessary during the course of the above mentioned operation/procedure.. I also consent to the administration of such anesthetic as are considered necessary for any of purposes. Any tissues or part surgically removed may be disposed off by treating doctors and /or Medical centre in accordance with accustomed practice. I also authorized the doctor to perform the above procedure/s at Oculus Healthcare or any other medical centre/setup considered appropriate by him/her. I hereby certify that I have read and fully understood the above Authorization for medical and/or surgical treatment the reason s why the above named surgery / procedure is considered necessary. Its advantage and possible complications, if any

as well as possible alternative modes of treatment which are explained to me by Dr. Manju Jain Verma/Dr. Ruma Gupta or other doctors of Oculus Healthcare. I also certify that no guarantee or assurance has been made as to the result that may be obtained.