This is to confirm, while I or my patient is being treated as an outpatient in the ManasPsych Health Clinic. I may undergo any type of examination, pills, medication, injection, blood test, narco-analysis, electro-convulsive therapy i.e. light treatment, anesthesia and any other examination and/or treatment/procedure/Therapy(CBT/REBT etc.)as advised by the doctor. The doctor has given us an idea about this treatment method and its potential risks. I am well informed in the language I understand. As the guardian of the patient/a close relative of the patient I want to get my patient treated at ManasPsych health clinic. We promise to stay with the patient continuously in the clinic and to follow all the rules of the Clinic to ensure that the patient does not run away. I/We also promise that we are legally responsible for paying the entire bill of the Clinic and in case of any vandalism or damage caused by the patient. I/My patient has no objection to starting Disulfiram, an anti-alcohol pill, and I will be fully responsible for any adverse reaction to drinking alcohol while on this pill. I have read and understood all the above contents and have signed the following consent form.
