{"text":"f \nName (Block Capitals) \nCONSENT TO ANAESTHESIA, OPERATION, INVESTIGATION OR TRiiATMENT ' \nPatient ID Label . DATE \nPROPOSED PROCEDURE \n(BLOCK CAPITALS) \nTO BE COMPLETED BY' CLINICAL PRACTITIONER \n1 HAVE FULLY EXPLAINED: To the patient\/\ufb01arent\/guardian \ni \\ . \n1. The procedlxre_nfzmed on this form. o oo \u00a2 \n2. Alternatives which are availat;le. \n3. Significant side effects which may r\u00e9sult fror\ufb01 the procedure. \n4. The use and implications of medical photography, video and audio. \n5. The need to read the patient information leaflet on the use of tissue for medical research and \nteaching. - . : : \nName (Block Capit\u00e9ls) ___.\u2014\u2014- Signature \nGrade\/Designation \n\/ \n1 AM The Patient\/Parent\/Gaurdian \nI UNDERSTAND The purpose, benefits and sngmflcaht risks associated with theprocedure which \nhave been explalned to me by the doctor named on this form. \nThat any procedure in addltlon to that named on this form WI\" only be carned out \n\u201cif 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.\u2018audi\u2019o\u2018recordings may subsequently be used \nfor consultation and teaching purposes. . \n1 \n~ That tlssue not essential for my diagnosis and future treatment may be used for \nmedical education and ethically. approved medlcal research. \nPlease tick box AGREE ] DISAGREE ] \nS \n_ Signature : Date \nAddress \nCedar No 00618 NO. 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