{"text":"Patient Agreement to Investigation or Treatment NHS \n| \u2014\u2014 \nConsent Form Greatzlrclasgow \nand Clyde \nPatient details (or pre-printed label) \nHospital \/ clinic \/ GP practice 0809555328 \nCLELLAND \n\u2014 - Agnes 08\/09\/195\u00a2 \nPatient\u2019s surname \/ family name 3 Ry;nme Road \n. LS \nGlasgow, Lanarkshire \nPatient\u2019s first name 665 9PQ \nDate of birth , ' Gender \n) Male D Female D \nCHI number \nSpecial requirements (e.g. other language \/ communication method) \nStatement for practitioner \n(to be filled in by practitioner with appropriate knowledge of proposed procedure) \nDescribe proposed operation, investigation or other treatment. \nWhere appropriate specify site or side (write in full). \nRigut - \ufb01zs'f_ MeTaTALRofAaaNGer. IOINT fugon) - \nT\/ Setens TOE oz sz \nSpecific risks \/ complications \nPlease detail any specific risk\/complications related to the procedure that were discussed. \nNoN \u2014 umon , IEaeD Usnons Swauwg STRAELC, \nNzaz\\%\\ve;&e_ INCIUPJ? VeEwoadt 'TT;\u2014MMBOQMZQUL?{\\' \nNF&\/:GD\u2018\\J\/ Wovee Puaprewn | \n[ have explained the procedure named on this form to the patient in terms which, in my \njudgement, are suited to their understanding. In particular, | have fully explained: the intended \nbenefits; appropriate alternatives which are available (including no treatment); any significant \nrisks which may result from the procedure; and any extra procedures which may become \nnecessary during the procedure (please specify major procedures above). | have explained who \nwill be doing the procedure if not myself. : \nA \u2014 \nName \/ Designation (print) \nN\\Q-P.Qf\\; \n| Date %\\\\ ]\\T\\ < - \nSignature of 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