{"text":"| I have explained the procedure named on this form to the patient in terms which, in my judgement, are \nPatient Agreement to Investigation or Treatment ~ NHS \nGreater Glasgow \n\/ and Clyde \nCONSENT FORM. \u201d \nPATIENT DETAILS (OR PRE-PRINTED LABEL) - \nHospital\/Clinic\/GP Practice ........v.ovvvveven... e e e, ! \nPatient\u2019s surname\/family name :........ e S \n\u2014p IR \nPatient\u2019s first name(s): ............ 10338654% P cesrreveerienserirecrnerssrienerestitnetnostiaetassnens \n- ' CLELLAND 08\/09\/1955 , \nDate of Birth__\/ \/ A EXNIE RORD ] Female [] \nKILSYTH Gges 9PQ \nNHS\/ CH[. Number ! i\ufb01s_oaossssaza L \nSpecial requirements (e.g. other language\/communication method) ... . \nT)-..........-...............................\\;: ........................................................................................ \nResponsible practitioner: .............2 (2\\-1 e e \nY < \nJOb title: evrrrririreiteeeieeen, Z\u2014\/\\CO\u201c\u2019)\"\"\u2019W ...................................... \nSTATEMENT FOR PRACTITIONER \n\u201c(to be filled in by practitioner with appropriate knowledge of. proposed procedure- see' gundance notes) \nDescrlbe- proposed operation, investigation or other treatment. \nWhere appropriate specify site or side: (WRITTEN IN FULL) \nWnermsimcaps 4 Yoo~ Ao \n. ' | | - .' - -e\ufb01()kcf:;\/\u2018c\u00ab\u00e9 ey \u2014~ \\M!P . \nL \nN \nsuited to their understariding. 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). \nSignature of practitioner: \nName\/Designation (Print) \nDate l\/ ................. 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