{"text":"fonersssT T S5THESIA, OPERATION, INVESTIGATION OR TREATMENT \n10338654)\u2018 \nF \nCLELLAND 08\/09\/1955 DATE . \/O& (0 \/\u20187[\u2014 \nAGNES \n39 Rennie Road \nGLASGOW PROPOSED PROCEDURE \n\"'i ces 520 o (BLOCK CAPITALS) s D @ S o \n. \\R\\\\W\\\\T\\\\M\\\\\\N\\\\ww 7 \/L7 \n1. \nName Blo;:k Capitals \n(. \u2018p ) -f\/] Q =< \nGradelDesignation \/ , \n[AM The PatlentIPa ntIGaurd:an \nSignature ifp\\\/n \nName (Block Capitals) \nAddress \nTO BE COMPLETED BY CLINICAL PRACTITIONER \n1 HAVE FULLY - EXPLAINED: To the patient\/parent\/guardian \nThe procedure named on this form. \nAlternatives which are available. \n. Significant side effects which may resuit from the procedure. \nThe use and implications of medical photography, video and audio. \nThe need to read the patient information leaflet on the use of tissue for medical research and \nteaching. <\u00a7\\ \nSignature : \nI UNDERSTAND The purpose, benefi ts and significant risks associated with theprocedure which \nhave been explained to me by the doctor named on this form. \noy \nThat any procedure in addition to that named on this form will only be carried out \nif it is necessary and in my best interests. \nThat the procedure may not be carried out by the doctor who has been treating \nme so far. ' \nThat any photographs, video and audio recordmgs may subsequently be used \nfor. consultatlon and teachmg purposes. \nThat tissue not essential for my dlagn05|s and future treatment may be used for \nmedical education and ethically approved medical research. \nPlease tic%?; AGREE E\/DlSAGREE ] \nA Date'_\ufb01k_\/_\u00e9)[_ \n174 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