Patient Agreement To Investigation Or Treatment (Page 4 of 7) in pdf

Patient identifier/label

Statement of patient

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

should already have your own copy of page 2 which describes the benefits and risks

of the proposed treatment. If not, you will be offered a copy now. If you have any

further questions, do ask - we are here to help you. You have the right to change

your mind at any time, including after you have signed this form.

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

I understand that you cannot give me a guarantee that a particular person will

perform the procedure. The person will, however, have appropriate experience.

I understand that I will have the opportunity to discuss the details of anaesthesia

with an anaesthetist before the procedure, unless the urgency of my situation

prevents this. (This only applies to patients having general or regional anaesthesia.)

I understand that any procedure in addition to those described on this form will only

be carried out if it is necessary to save my life or to prevent serious harm to my

health.

I have been told about additional procedures which may become necessary during

my treatment. I have listed below any procedures which I do not wish to be

carried out without further discussion.

…………………………………………………………………………………………………

Patient's signature …………………………………… Date ….…..…………………….

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

A witness should sign below if the patient is unable to sign but has indicated

his or her consent. Young people/children may also like a parent to sign here

(see notes).

Signature ……………………………………………

Date ……………….………….

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

Confirmation of consent (to be completed by a health professional when the

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

On behalf of the team treating the patient, I have confirmed with the patient that s/he

has no further questions and wishes the procedure to go ahead.

Quality and Governance Service

Updated November 2013

Patient Agreement To Investigation Or Treatment Page 4