{"text":"\\ \n&E@m\ufb01@@e&ym\ufb02\ufb01a\ufb01\ufb02 s, \n\u00a9penante) respendiiy Gor & milver wilhewt epady) \nYou should read thlS form and the notes below careftilly. If there is anything you do not \nunderstand ask the Practitioner for an explanation. If the information is correct and you \n| understand the procedure, you should sign the form. You have the right to change your mind at \n-1 any time, including after you have signed this form. \nN understand \nThe procedure, important risks and appropriate alternatives whach have been explalned to \nme by the practitioner named on this form. \nWho will be performing my procedure on the day \nThat 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.\u2019 \nThat examination for the purpose of teaching will not be undertaken without my consent. \nI have b\u00e9en told about additional procedures which may become necessary during treatment. \nI have listed below any procedures which | do NOT wrsh to be carried out without further \n. discussion. \n| agree . \no to the administration of an anaesthetic or to sedation if required, \ne to the procedure named on this form, \n\u00b0 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 ethlcally-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. \nm\ufb02g\ufb02m\ufb01@mmm \nSignature _ . \u2014 | Date \n\u00b0 \ufb02M\/) ' ~ t \u00e9 Of | & \nName (pnnt) lA\u2019G\u2019NG\ufb02 % Q'VU\\D : \n| ettt wefiuet) o itowd) produats \nPlease sign here if you refuse to consent to the emergency administration of bIood of blood \nproducts, even if this results in death. \nSignature Date \nSignature of practitioner o : ' \" | Date \n\u2019 \nMl \u00bb 270008 Version 1_0 \u00ab GGCQ003 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