{"text":"e T \n4.\u201c2\u2018:'; LSBT o8 \n'You should read this form and the notes below carefully If there is anything 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, important risks and appropriate alternatives which have been explained to me by \nthe practitioner named on this form. \n- that a practitioner other than the practitioner who has been providing treatment so far might \ncarry 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.,\u2019 \n-~ \n| agree - \n\u00bb to the administration of an anaesthetic or to sedation if required. \ne to the procedure named on this form \n\u00bb that the examination for the purposes of teaching will not be undertaken without my consent \n* to 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 \nAdditionally you have to agree or disagree the folldwing:- Agree Disagree \nthat information and\/or images kept in records may be used anonymously \nfor education, audit, and research with appropriate ethical approval, to _ LA \n1prove 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. \nB I e e e I ) \n5 \u2018.PATIIENT\"AGREEMENI} -OR: \nA AT A \u00a3 R PR 5 PR e TR S ~:\"; e \n| confirm that | have no further questions and wish the procedure to go ahead. \n| Signature: .......ooeiiiniiinnnnne, et Printname.........ccoiviis 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