{"text":"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 approprlate alternatives whlch have been explamed to me by \nthe practitioner named on this form. \n- that a practitioner other than the practitioner who has been providing. treatment so far mlght \ncarry out the procedure \n- thatany procedure in addition to that named on this form will only be carried out if it is necessary \nand s reasonable in the circumstances, in relation to the medical treatment proposed, to safeguard \nor promote physical or mental health. \n| ! 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\u2019 \n| agree - \n* to the administration of an anaesthetic or to sedation if required. \n| *. to the procedure named on this form \n* 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 Date ......... [veienn [oveiniiinnan \nAdditionally you have to agree or disagree the following:- Agree Disagree \nthat 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. \nSignattxre%f..&.ft.. ; Date . [c\u2018 .......... 1.6 \nName (Primt e iiieieiteeeernaesiietiea et anes ertreriereeeae, Cereereraeaenninnes \nURAERRCAE LN \n10338654X \nCLELLAND F \nAGNES 08\/09\/1955 \n39 RENNIE ROAD \nKILSYTH . \nGLASGOW . G65 9PQ \n| confirm 1 c#x-0s09sss32e , stions and wish the procedure to go ahead. \nSignature: .............. 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