{"text":"\u2019 \nCONSENT TO ANAESTHESIA, OPERATION, INVESTIGATION OR TREATMENT . . \nWOMOGERORE oare 2k \n10338654X ; ' - \n. aowes 08\/05\/105, PROPOSED PROCEDURE M( [ \n39 Rennie Road (BLOCK CAPITALS) ' { \u2019 5 ms CI? Z \nKilsyth . ' \nGLASGOW \u00b0 G65 SPQ n - - \nCHI-0809555328 . 1 \u2018 . \n' Be wrvean s o \u2014- \u2014\u2014NICAL PRACTITIONER e \n1 HAVE FULLY EXPLAINED: To the\/patient\/ arent\/guardian \n1. The procedure named on this form. \n2. Alternatives which are available. \n3. Significant side effects Whi_ch may\\r_esult from the procedure. \n4. Theuse 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 Capitals) - W_\\ Signature : W \n, Grade\/Designation \/% \n\u2014 \n| AM The Patient\/Parent\/Gaurdian \n1 UNDERSTAND The purpose, ben\u00e9\ufb01ts and significant risks associated with theprocedure which \no have been explained to me by the doctor named on this form. \n- \nL \nTt \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 recordings may subsequently be used \nfor consultation and teaching' purposes. ' \nThat tissue not essential for my diagnt\u201cqsis and future treatment may be used for \nmedical education and ethically approved medical research. \n\" Pleasetickbox AGREE DISAGREE ?[ \nSignature \u2014y@\\,\u2019{\u201c\u2019uov\u00e9k\/\u2019v\u2018; Date \u2019J\/ \/\/ ) - o \nName (Block Capitals) \nAddress \nCedar No 00618 NO. 16 MIS 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