{"text":"Statement of patient \nPlease read this form carefully. If your treatment \nhas been planned in advance, you should \nalready have information which describes the \nbenefits and risks of the proposed treatment. If \nnot, you will be offered this information now. if \nKoy nave any further questions, do ask \u2014 we are \nere fo help you. You have the right to change \nyour mind at any fime, including affer you have \nsigned this form. \n- | Clelland \u00a2 Agnes . _l \nPatient jdentifier\/label \n3? \u20acnnie Road . \nG65 9PQ \n08\/09\/1055 \n(Femaje 31569 \nT Robert Carter 1 ll!l!&ll!\ufb02l!![ll! i} II}II i \nI agree to the procedure or course of treatment described on this form \nI understand that | will | \ninless the f \nhave the opportunity to discuss the details of ancesthesiawith an anaesthefist before the \nurgency of my situation prevents this. {This only applies to patients having general or regional anaesthesia). \nI understand that any procedure in addition o thos \ne described on this form will only be carried out if i is necessary \nto-save the life or to prevent serious harm to my health. \n~ \nDate_-11 I%(fb - \nPatients signature s{_ ['SNA&&& =N \nName (PRINT) \u00bb \nA witness should sign below if the patient is unable to sign but has indicated his or her consent. \n===g people may also like a parent to sign he\u00e9re (see nofes) \n\u2014 \nSignature - . Date \nName (PRINT) \n:O\ufb02firma\ufb01on Of consent (i be completed by the consultant or admitiin \ng registered nurse when the patient is admitted for the \nrocedure, if the patient has signed the form in advance) \nhave confirmed with the patient that he\/she has no further questions and wishes the proposed procedure\/ireatment \nngo ahead. \nigned Dafe. \nlame (PRI NT)' Jobtitle \nnporfant notes ick if applicable) \n| See.also advance directive,\/ fiving will \nPatient has withdrawn consent (ask patient to sign \/date here) - > \nAT b e o ke 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