{"text":"Consent form 1 \nPatients agreement to investigation or treatment . \nPa;ieni details \nPatient\u2019s sumame\/family name \u2018 Patient\u2019s first names \nDate of birth ' Age Consultant \nHospital number Special requirements \nO Male : O Female {eg other language\/other communication method) \nName Of proposed prbcedure or course Of treatment (include brief explanation if medical term not clear} \n\\evlc\u2018\ufb01f DT OS1Iord \nStatement of consultcml'\/ health professidnal (to be filled in by consultant\/health professional with appropriate \ndge of the proposed procedure or course of treatment) \u2019\u201c} \n. . . : . . -~ \nI hdve explained the procedure to the patient. In particular, | have explained: Y \nThe intended benefits \nVD oue p&flfx \nSerious or frequently occurring risks \n\\QQLC\\\/\\\/VWLQ \nAny extra procedures which may become necessary during the procedure (tick if applicablel \nJ blood transfusion [J use of human organs and tissue \nJ other procedure (please specify) \nhave also discussed what the procedure is likely to involve, the benefits and risks of any available alternative \nents (including no treatment) and any particular concerns of this patient. {iick if applicable) \n- 9 y P P PP \n_\ufb01z\u2018V% \n7 The following leaflet\/tape has-been provided Description P \nhave discussed what the anaesthetic procedure is likely to involve, the benefits and risks of any available alternative \nmaesthetics and any particular concerns of this patient. ' \nhis procedure will involve: \nf{gen%gional anaesthesia 0 O local anaesthesia 0 70tion _ \nigned C)JZQ_\/\u2018 f _ Dae ([ \/3 \/{0 \/[ 03 s \nS \nlame (PRINT) \" A finge, \u2019 \n.ontact del'ails (if patient wish to discuss options later) \ntatement Of inferprel\u2018er (where appropriate} \nhave interpreted the information above to the patient to the best of my ability and in a way in which | believe \ne\/she can Understand. \nigned_\u2018 Date \nlame (PRINT) \nopy accepted by patient: yes\/no (plecse ring) \n\u00bbp copy to be retained in clinical records - middle copy to be given to patient - bottom copy to be retained by 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