Patient Agreement To Investigation Or Treatment Page 5

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

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

Job Title …………………………………………………………………………………….

Important notes: (tick if applicable)

See also advance directive/living will (e.g. Jehovah's Witness form)

Patient has withdrawn consent (ask patient to sign/date here)

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

Quality and Governance Service

Updated November 2013

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Parent category: Business