{"text":"You should read this form and the notes below carefully. If there is anything you do not understand | \nask the Practitioner for an explanation. If the information is correct and you understand the procedure, \nyou should sign the form. You have the right to change your mind at any time, including after you \nhave signed this form. \n| understand \n- the procedure, important risks and approprlate alternatives which have been explained to me by \nthe practitioner named on this form. \n- that a practitioner other than the practitioner who has \u2018been providing treatment so far might \ncarry out the procedure. \n- that any procedure in addition to that named on this form will only be carried out if it is necessary \nand is reasonable in the circumstances, in relation to the medical treatment proposed, to safeguard \n-or promote physical or mental health. \n- That examination for the purpose of teaching will not be undertaken without my consent. \nI have been told about additional procedures which may become necessary during treatment. | have \nted below any procedures which | do NOT wish to be carried out without further discussion. \n| agree - \n* to the administration of an anaesthetic or to sedation if required. \ne to.the procedure named on this form \n* to the emergency administration of blood or blood. products \nAddltlonally you have to agree or dlsagree the followmg - Agree \/Disagree \nthat information and\/or images kept in records may be used anonymously l\/ \nfor education, audit, and research with approprlate ethical approval, to \nimprove the quality of patient care. \nthat surplus tissue or other biological material not essential for my diagnosis or \nJture treatment may be used for medical education and ethically approved \nmedical research. \ne R \n: \nPATIENT \ne et s \n| Please sign here if you refuse to consent to the emergency administration of blood or blood \nproducts. Even if this results in death. \nSIGNALUTES L vveeeevieceieeere e evee e e eeneeeereeeeerseeseneeeeereeesaseanees Date ..vovolfeernn, [everrianaanne \nPractitioner Signature: ......ccoiuiiieveieniiiiiicre e Date ......... Jovinnnnn [oeeiiiiinnnn \nSignature: ...... D \nName (Print): ....... iilerrereeeesetieeneecatiieneteranatirirearesneaerreesaeens et reerara et ST \nMIS 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