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HT_0709_consent 1

Statement of patient

Please read this form carefully. If your treatment has been planned in advance, you should already have your

own copy, which describes the beneﬁts and risks of the proposed treatment. If not, you will be offered a copy

Consent Form

now. If you have any further questions, do ask - we are here to help. You have the right to change your mind at

Patient Agreement to Investigation or Treatment

any time, including after you have signed this form.

I agree to the procedure or course of treatment described on this form.

Patient details (or pre-printed label)

I understand that you cannot give me a guarantee that a particular person will perform the procedure. The

Patient’s surname/family name ............................................... Patient’s first names ....................................................

person will, however, have appropriate experience.

Date of Birth............................................................................. Male

Female

NHS number ............................................................................. PID ................................................................................

I understand that I will have the opportunity to discuss the details of anaesthesia with an anaesthetist before

Responsible health professional.......................................................................................................................................

the procedure, unless the urgency of my situation prevents this (this only applies to patients having general

Job title ..................................................................................... Registration number...................................................

anaesthesia).

Special requirements.........................................................................................................................................................

(eg other language/other communication method)

I understand that any procedure in addition to those described on this form will only be carried out if it is

Name of proposed procedure or course of treatment

(include brief explanation if medical

necessary to save my life or to prevent serious harm to my health.

term not clear): .................................................................................................................................................................

I have been told about additional procedures which may become necessary during my treatment. I have listed

...........................................................................................................................................................................................

here any procedures which I do not wish to be carried out without further discussion, even if I become at risk of

Statement of health professional

death:.................................................................................................................................................................................

(to be ﬁlled in by health professional with appropriate

...........................................................................................................................................................................................

knowledge of proposed procedure, as speciﬁed in consent policy and delegated consent policy)

I have read and understood the guidance to health professionals overleaf.

I consent/do not consent to the removal of my tissue and/or blood products during this operation and

I consent/do not consent to its use for (tick as applicable):

I have explained the procedure to the patient, in particular, I have explained:

Research in connection with disorders and/or the functioning of the human body

The intended beneﬁts: ......................................................................................................................................................

Obtaining scientific or medical information about a living or deceased person which may be relevant to

.............................................................................................................................................................................................

any other person (including a future person)

.............................................................................................................................................................................................

Patient’s signature................................................................................................Date......................................................

The signiﬁcant, unavoidable or frequently occurring risks:............................................................................................

Name (PRINT).................................................................................................................... . ..................................................

............................................................................................................................................................................................

A witness should sign below if the patient is unable to sign but has indicated his or her consent. Young people

Any extra procedures which may become necessary during the procedure:

/ children may also like a parent to sign here.

Blood transfusion ................................................................................................................................................

Signed....................................................................................................................Date......................................................

Name (PRINT).................................................................................................................... . ..................................................

Other procedures (please specify):......................................................................................................................

..............................................................................................................................................................................

Conﬁrmation of consent

I have also discussed what the procedure is likely to involve, the beneﬁts and risks of any available alternative

(be completed by a health professional and the patient when the patient is

treatments (including no treatment) and any particular concerns of this patient.

admitted for the procedure, if the patient has signed the form in advance)

The following leaﬂet/CD/DVD has been provided..............................................................................................

On behalf of the team treating the patient, I have discussed the treatment with the patient and answered any

This procedure will involve:

further questions or concerns. I have also conﬁrmed with the patient that she/he has made an informed decision

General anaesthesia

Local anaesthesia

Sedation

and wishes to go ahead.

Signed ................................................................................................................. Date ....................................................

Name (PRINT)...................................................................................................... Job Title..............................................

Health Professional

Signed ................................................................................................................. Date ....................................................

Statement of interpreter

(where appropriate)

Name (PRINT)...................................................................................................... Job Title..............................................

I have interpreted the information above to the patient to the best of my ability and in a way in which I believe

Patient

she/he can understand.

Signed ................................................................................................................. Date ....................................................

Signed .......................................................................................................................Date..................................................

Name (PRINT) ....................................................................................................................................................................

Name (PRINT)......................................................................................................................................................................

Important notes: (tick if applicable)

See also advanced decision to refuse treatment/living will (e.g. Jehovah’s witness form)

Patient has withdrawn consent, patient to sign and date here to conﬁrm.....................................................

Copy accepted by patient: yes / no (please ring)

YELLOW COPY: CASE NOTES

WHITE COPY: PATIENT

HWZ0803S