{"text":"STATEMENT TO,BE COMPLETED BY PATIENT\/PARENT? \nT w1thout capa _ \nYou shouid read this form and the notes below carefully If there is anythmg you do not understand \nask the Practitioner for an explanation. If the information is correct and you understand the procedure, \nyou should sign the form. You have the right to change your mind at any time, including after you \nhave signed this form. \nI understand \n- the procedure, |mportant risks and appropriate alternatives which have been explalned to me by \nthe practitioner named on this form. \n- that a practitioner other than the practitioner who has been prowdlng treatment so far might \n\u201ccarry out the procedure. \n- that any procedure in addition to that named on this form will only be carried out if it is necessary \nand is reasonable in the circumstances, in relation to the medical treatment proposed, to safeguard \nor promote physical or mental health. \nI have been told about additional procedures which may become necessary during treatment. [ have \nlisted below any procedures which | do NOT wish to be carried out without further discussion. \n| agree - \nto the administration of an anaesthetic or to sedation if required. \n* to the procedure named on this form \nthat the examination for the purposes of teaching will not be undertaken without my consent \nto the emergency administration of blood or blood products \nPlease sign here if you refuse to consent to the emergency administration of blood or blood \nproducts. : \nSignature ................ et '~ Date......... \/A Joveearienans \nAdditionally you have to agree or disagree the following:- Agree Disagree \n- | that information and\/or images kept in records may be used anonymously \nfor education, audit, and research with appropriate ethical approval, to \nprove the quality of patient care. \nthat surplus tissue not essential for my diagnosis or future treatment may \nbe used for medical education and ethically approved medical research. \nSignature: ...o.ceeiiiieninn et teereee \n| Name (Print): ........coeneeee e e e et e e \nto:be completed \n| confirm that | have no further questions and wish the procedure to go ahead. \nSignature: ...oooiviviinnniien fveens PN MAMC. c.vvevreveereeeseeseesrerneesessneesesionsenne \nCedar No 00618 NO.16 MIS 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