Patient Agreement To Investigation Or Treatment Page 3
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7Contact details (if patient wishes to discuss options later)
………………………………………………………………………………………………….
Statement of interpreter (where appropriate)
I have interpreted the information above to the patient to the best of my ability and in
a way in which I believe s/he can understand.
Signed: ……………………………………………
Date ……...................................
Name (PRINT) …………………..…………………….…………………………………..
Top copy accepted by patient: Yes / No (please circle)
Quality and Governance Service
Updated November 2013
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