Patient Agreement To Investigation Or Treatment (Page 2 of 7) in pdf

Patient identifier/label

Name of proposed procedure or course of treatment (

Include brief

explanation if medical term is not clear)

…………………………………………………………………………………………………..

………………………………………………………………………………………………..

Statement of health professional

(to be filled in by health professional with

appropriate knowledge of proposed procedure, as specified in consent policy).

I have explained the procedure to the patient. In particular, I have explained:

The intended benefits

………………………………………………………………………………………………..

Significant, unavoidable or frequently occurring risks

…………………………………………………………………………………………………..

Any extra procedures which may become necessary during the procedure:

Blood transfusion

…………………………………………………………………………...…………………….

Other procedure (please specify)

…………………………………………………………………………………………………

……………………………………………………………………………………………….

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

any available alternative treatment (including no treatment) and any particular

concerns of patient.

The following leaflet/tape has been provided

…………………………………………………………………………………………………

This procedure will involve:

General and/or regional anaesthesia

Local anaesthesia

Sedation

Signed: ………………………………………. Date ……………………………………..

Name (PRINT) ………………………………………………………………………………

Job title ………………………………………………………………………………………

Quality and Governance Service

Updated November 2013

Patient Agreement To Investigation Or Treatment Page 2