Dr. __________(Name of the Doctor)
__________(Name of the Hospital)

Date: __/__/____(Date)

Subject: Declaration for treatment

Respected Sir/Madam,

With due respect, I __________(Name of the Patient) having Patient ID __________(Patient ID) got admitted to your __________(Hospital/ Clinic) on ________(Date). After getting all tests done, the results stated that I need to have a __________ (Surgery/ Operation) of __________(Name of the treatment).

Therefore, I am writing this letter to state that I authorize __________(Name of the Doctor) for the medical treatment decisions on the provided date __________(Mention Date).

I have read all terms and conditions and I hereby declare that as per rules stated by the __________(Hospital/ Clinic), I agree with the rules mentioned in __________ (annexure/form/application).

Yours Sincerely/ Faithfully,

__________(Name of the Patient)

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