{"text":"Patient Agreement to Investigation or Treatment T \" NHS \n. ) . . \u2019 Great%r(\u00e9z:jsjw \nand Clyde \nCONSENT FORM - \ne \nP RENNIE ROAD \nDate of Birth___\/ \/ LT s s Ve [ Female O \n\\ . . _ . \n(Special requirements (e.g. other l,a\u2018nguage\/communication MEthod) \u00aboveeenirnimierieeniinianeen, fenernns \nHospital\/Clinic\/GP Practice ............. e eeerieseseeiesaeesenseeasesessieiiatiaasiatenitienng e \nPatient\u2019s Asurname\/fam.ilr)( na \\\\\u201c\\\\\\m\\\\\\\\\u201c\\m\\\\\\\\\\\\\u201c\\\\\\\\m\\\\\\\\\\\\\\\u201c | rerve s s s e \nPatient\u2019s first name(s): ....... lcfgi\ufb01;x 08\/09 ;1951; ............................. wanraneas s e \nGLASGOW \nCHI-0809555328 \nNHS\/ CHI Number \n\u2018 \n1 \n\u2018| Where appropriate specify site or side: (WRITTEN IN FULL) \nN Erasion) RIOST. oF WMVD \nDescribe proposed operation,' investigation or other treatment. \n\u00ae Bk | \nX\/Uual\ufb01 - %\/}@l M\u2018J@@f\ufb02\\\/ 7@\/7\/1f B\u2014JCM \n| have explained]the procedure named on this form to the patient in terms which, in my judgement, are \nsuited to their understanding. In particular, | have fully explained: the intended benefits; appropriate \nalternatives which are available (including no treatment); any significant risks which may result from \nthe procedure; and any extra procedures which may become necessary during the procedure (please \nspecify major procedures above). \u2019 \nSignature of practitioner: . < ............................................. \nName\/Designation 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