{"text":"Acute Services Division N H S \nDiagnostics Directorate m\u2018 \u2019\ufb02\u2018\/ \nDepartment of Pathology Greater GIESQOW \nSpecialty: Trauma and Orthopaedic Surgery and Clyde \nSTA Form Release 1.1 RC 1.1 \ne et oo o \n5 HOSPltal Name-'Glasgow Royal Infirmary \n! , e . \nPatient Detalls GP Details _ \n(S \nP i Name'h\ufb02\u00e9\ufb01}g CLELLAND | Name-iSTAFFORD ELIZABETH ] \n; Address: 39 RENNIE ROAD | Address:| Kjlsyth Community Health Centre \n; |KILSYTH j ! Airdrie Road \ni i Glasgow \u00a7 i Kilsyth \ni Lanarkshire : . \u2018 ; \n: e e+ e | - ) \nPostcode: Gg5 9PQ 3 Telephone: | \nCorrespondence Addressl \u00a7 \n; Correspondence.. Addressz ' T \u201c\u2014% : \nCorrespondence Postcode CoTm | \n! Te[ephone: T T T \nj e e e e e e e \ni \/CHI Number. 0809555328 \u2018 Consent.;Yes \nCRN ?6352355&\"\" ZMOB407457, y Sen5|t|VltY=\u00a7S\ufb01enws;El;e T \n179344885, 0809555328 i \n: o N NP A AN ML LIS N bt \nD.0.B: 08\/09\/1955 \n% o e i TN 131t i ottt o \ni T Sex. Female \nForm Date:| |15\/06\/2017 \u2019 \n| Yes | No \n1. Did you receive the patlent leaflet \"The Use of Surplus Tlssue for | e \nMedical Research & Education\u2122? ' \n: 2. Does the patient reqmre further information from the Bio Repository ; o \n\u2018Nurses\" : ! \nDo you agree that surplus tissue not essential for your diagnosis or \u00b0 \nfuture treatment may be used for medical, education and ethically \napproved medical research? \nW \nil Withdrawl of Authorisation \nDate of With\u2018drawl - \nComments o . | \ni \ni If a patient withdraws authorisation please complete the date and any mformatlon \n_relating to the reason for withdrawal in the comments field. \n{ 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