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' \n! understand \n- The procedure, important risks and appropriate alternatives which have been explained to \nme by the practitioner named on this form. \n- Who will be performing my procedure on the day \n- That any procedure in addition to that named on this form will only be carried out if it \nis necessary and is reasonable in the circumstances, in relation to the medical treatment \nproposed, to safeguard 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. \n| 1 have listed below any procedures which | do NOT wish to be carried out without further \ndiscussion. \n1 agree \n\u00ab to the administration of an anaesthetic or to sedation if required, \ne to the procedure named on this form, \n\u00bb to the emergency administration of blood or blood products. \nAdditionally you have to agree or disagree to the following Agree Disagree \nto photographic images and video recordings being held in records, and \nmade available for teaching, audit and ethically-approved research purposes, \nto improve the quality of patient care. \nthat surplus tissue or other biological material not essential for my diagnosis \nor future treatment may be used for medical education and ethically . \napproved medical research. \nPatient \/ parent agreement to treatment \nSignature \/ | \u2018 Date \n2\\ \u00a2 \n7 7 \n- _ \nName (print) o \nPeneS (eercARA) | | \n| Please sign here if'you refuse to consent to the emergency administration of blood or blood \nproducts, even if this results in death. \nSignature : ' Date \nSignature of practitioner Date \nmi \u00ab 270008 Version 1.0 \u00a2 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