{"text":"You should read this form and the notes below carefully. If there is anythlng 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 rlght to change your mind at any time, including after you \nhave signed this form : \n| understand \n- the procedure, important 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 prov1dlng 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 \n. and is reasonable in the circumstances, in relation to the medical treatment proposed, to safequard \n, or promote physical or mental health. \n- That examination for the purpose of teaching will not be uridertaken without my consent. \n-~ \nI have been told about additional procedures which may become necessary during treatment. | have \nq listed below any procedures which | do NOT wish to be carried out without further discussion. \n| agree - \n* to the administration of an anaesthetic or to sedation if required. \ne to the procedure named on this form \n* to the \u2018emergency admlmstratlon of blood or b!ood products \nAdditionally you have to agree or disagree the following:- . Agree Disagree \nthat information and\/or images kept in records may be used anonymously L \nfor education, audit, and research with appropriate ethlcal approval, to 1 \nimprove the quality of patient care. \nthat surplus tissue or other biological material not essential for my diagnosis or [ ] \nre treatment may be used for medical education and ethically approved \nmedical research. \nPlease sign here if you refuse to consent to the'@mergency administration of blood or blood \nproducts. 'Even if this results in death. \nSignatur\u00e9: ..................................................... et ' Date ......... 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