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\brdrl\brdrtriple\brdrw10\brsp80 \brdrb\brdrtriple\brdrw10\brsp20 \brdrr\brdrtriple\brdrw10\brsp80 \wrapdefault\faauto\adjustright\rin0\lin0\rtlgutter\itap0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 \par }\pard \ltrpar\ql \fi720\li0\ri0\sa40\widctlpar\brdrt\brdrtriple\brdrw10\brsp20 \brdrl\brdrtriple\brdrw10\brsp80 \brdrb\brdrtriple\brdrw10\brsp20 \brdrr\brdrtriple\brdrw10\brsp80 \wrapdefault\faauto\adjustright\rin0\lin0\rtlgutter\itap0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 Date of birth \'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85. \par }\pard \ltrpar\qc \li0\ri0\sa40\widctlpar\brdrt\brdrtriple\brdrw10\brsp20 \brdrl\brdrtriple\brdrw10\brsp80 \brdrb\brdrtriple\brdrw10\brsp20 \brdrr\brdrtriple\brdrw10\brsp80 \wrapdefault\faauto\adjustright\rin0\lin0\rtlgutter\itap0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 \par }\pard \ltrpar\ql \fi720\li0\ri0\sa40\widctlpar\brdrt\brdrtriple\brdrw10\brsp20 \brdrl\brdrtriple\brdrw10\brsp80 \brdrb\brdrtriple\brdrw10\brsp20 \brdrr\brdrtriple\brdrw10\brsp80 \wrapdefault\faauto\adjustright\rin0\lin0\rtlgutter\itap0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 Responsible health professional.\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85 \par \par Job title \'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85. \par }\pard \ltrpar\qc \li0\ri0\sa40\widctlpar\brdrt\brdrtriple\brdrw10\brsp20 \brdrl\brdrtriple\brdrw10\brsp80 \brdrb\brdrtriple\brdrw10\brsp20 \brdrr\brdrtriple\brdrw10\brsp80 \wrapdefault\faauto\adjustright\rin0\lin0\rtlgutter\itap0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 \par }\pard \ltrpar\ql \fi720\li0\ri0\sa40\widctlpar\brdrt\brdrtriple\brdrw10\brsp20 \brdrl\brdrtriple\brdrw10\brsp80 \brdrb\brdrtriple\brdrw10\brsp20 \brdrr\brdrtriple\brdrw10\brsp80 \wrapdefault\faauto\adjustright\rin0\lin0\rtlgutter\itap0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 NHS number (or other identifier)\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85.. \par \par }{\rtlch\fcs1 \af1\afs32 \ltrch\fcs0 \fs32\insrsid9334144 {\field{\*\fldinst SYMBOL 255 \\f "Symbol" \\s 16}{\fldrslt\f3\fs32}}}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 Male\tab \tab \tab }{\rtlch\fcs1 \af1\afs32 \ltrch\fcs0 \fs32\insrsid9334144 {\field{\*\fldinst SYMBOL 255 \\f "Symbol" \\s 16}{\fldrslt\f3\fs32}}}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 Female \par \par Special requirements \'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85 \par (eg other language/other communication method) \par }\pard \ltrpar\qc \li0\ri0\sa40\widctlpar\brdrt\brdrtriple\brdrw10\brsp20 \brdrl\brdrtriple\brdrw10\brsp80 \brdrb\brdrtriple\brdrw10\brsp20 \brdrr\brdrtriple\brdrw10\brsp80 \wrapdefault\faauto\adjustright\rin0\lin0\rtlgutter\itap0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 \par }\pard \ltrpar\qc \li0\ri0\sa40\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 \par }\pard \ltrpar\ql \li0\ri0\sa40\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 \par \par \par }\pard\plain \ltrpar\s7\qc \li0\ri0\sa40\keepn\widctlpar\wrapdefault\faauto\outlinelevel6\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \ab\af1\afs28\alang1025 \ltrch\fcs0 \b\f1\fs28\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 To be retained in patient\rquote s notes\sect }\sectd \ltrsect\marglsxn1134\margrsxn1134\margbsxn284\linex0\headery709\footery709\colsx709\endnhere\sectdefaultcl\sftnbj \pard\plain \ltrpar \s3\ql \li0\ri0\sa40\keepn\widctlpar\wrapdefault\faauto\outlinelevel2\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \ab\af1\afs24\alang1025 \ltrch\fcs0 \b\f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 Patient identifier/label \par }\pard\plain \ltrpar\ql \li0\ri0\sa40\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs24\alang1025 \ltrch\fcs0 \f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\insrsid9334144 \par }\pard\plain \ltrpar\s3\ql \li0\ri0\sa40\keepn\widctlpar\wrapdefault\faauto\outlinelevel2\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \ab\af1\afs24\alang1025 \ltrch\fcs0 \b\f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1\afs32 \ltrch\fcs0 \fs32\insrsid9334144 Name of proposed procedure or course of treatment}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 }{\rtlch\fcs1 \ab0\af1\afs28 \ltrch\fcs0 \b0\fs28\insrsid9334144 (}{\rtlch\fcs1 \ab0\af1 \ltrch\fcs0 \b0\insrsid9334144 inc lude brief explanation if medical term not clear}{\rtlch\fcs1 \ab0\af1\afs28 \ltrch\fcs0 \b0\fs28\insrsid9334144 ) \'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85. \par }\pard\plain \ltrpar\ql \li0\ri0\sa40\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs24\alang1025 \ltrch\fcs0 \f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \fs28\insrsid9334144 \'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85 \'85\'85\'85\'85\'85\'85\'85\'85\'85\'85 \par \par }\pard\plain \ltrpar\s2\ql \li0\ri0\sa40\keepn\widctlpar\wrapdefault\faauto\outlinelevel1\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \ab\af1\afs24\alang1025 \ltrch\fcs0 \b\f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1\afs32 \ltrch\fcs0 \fs32\insrsid9334144 Statement of health professional}{\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \fs28\insrsid9334144 }{\rtlch\fcs1 \ab0\af1\afs28 \ltrch\fcs0 \b0\fs28\insrsid9334144 (}{\rtlch\fcs1 \ab0\af1 \ltrch\fcs0 \b0\insrsid9334144 to be filled in by health professional with appropriate knowledge of proposed procedure, as specified in consent policy}{\rtlch\fcs1 \ab0\af1\afs28 \ltrch\fcs0 \b0\fs28\insrsid9334144 ) \par }\pard\plain \ltrpar\ql \li0\ri0\sa40\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs24\alang1025 \ltrch\fcs0 \f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 \par I have explained the procedure to the patient. In particular, I have explained: \par \par The reasons for doing the procedure.\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85..\'85\'85\'85.\'85\'85\'85 \par \'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85.. \'85\'85\'85\'85\'85\'85\'85\'85\'85\'85..\'85\'85\'85\'85\'85\'85 \par Serious or frequently occurring risks \'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85...\'85\'85\'85\'85\'85\'85 \par ...\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85.\'85\'85\'85\'85\'85 \par Infection\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85.\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85..\'85\'85\'85\'85\'85\'85\'85\'85. \par \'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85..\'85\'85.\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85. \par Development of acute compartment syndrome\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85...\'85\'85...\'85\'85\'85\'85\'85.\'85..\'85\'85. \par \'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85...\'85\'85\'85\'85\'85\'85\'85.\'85..\'85\'85. \par \par I have also discussed what the procedure is likely to involve, the benefits and risks of any available alternative treatments (including no treatment) and any particular concerns of this patient. \par \par }{\rtlch\fcs1 \af1\afs32 \ltrch\fcs0 \fs32\insrsid9334144 {\field{\*\fldinst SYMBOL 255 \\f "Symbol" \\s 16}{\fldrslt\f3\fs32}}}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 The following leaflet/tape has been provided \'85 Oxsport Patient information leaflet for compartment pressure testing\'85\'85\'85\'85\'85.\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85..\'85 \par \par This procedure will involve: \par }\pard\plain \ltrpar\s19\ql \li0\ri0\sa40\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs24\alang1025 \ltrch\fcs0 \f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 \tab } {\rtlch\fcs1 \af1\afs32 \ltrch\fcs0 \fs32\insrsid9334144 {\field{\*\fldinst SYMBOL 255 \\f "Symbol" \\s 16}{\fldrslt\f3\fs32}}}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 local anaesthesia\tab \par }\pard\plain \ltrpar\ql \li0\ri0\sa40\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs24\alang1025 \ltrch\fcs0 \f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 \par Signed:\'85\'85.\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\tab \tab Date .. \'85\'85\'85\'85\'85\'85\'85\'85.\'85\'85\'85. \par Name (PRINT) \'85\'85\'85\'85\'85\'85\'85\'85\'85. \'85\'85\'85\tab \tab Job title \'85\'85.. \'85\'85\'85\'85\'85\'85\'85.\'85 \par \par }{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\insrsid9334144 Contact details }{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 (if patient wishes to discuss options later) \'85..\'85\'85\'85\'85\'85\'85.\'85\'85\'85\'85\'85 \par }\pard\plain \ltrpar\s19\ql \li0\ri0\sa40\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs24\alang1025 \ltrch\fcs0 \f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 \par }\pard\plain \ltrpar\ql \li0\ri0\sa40\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs24\alang1025 \ltrch\fcs0 \f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\fs28\insrsid9334144 Statement of interpreter}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 (where appropriate) \par }\pard\plain \ltrpar\s19\ql \li0\ri0\sa40\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs24\alang1025 \ltrch\fcs0 \f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 \par }\pard\plain \ltrpar\ql \li0\ri0\sa40\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs24\alang1025 \ltrch\fcs0 \f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 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. \par \par Signed \'85\'85\'85\'85\'85\'85\'85\'85\'85\'85.\'85\'85\'85\'85\'85\'85\'85\'85.\tab Date \'85\'85\'85\'85\'85\'85..\'85\'85\'85\'85\'85. \par Name (PRINT) \'85\'85\'85\'85\'85\'85\'85..\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85 \par }\pard\plain \ltrpar\s19\ql \li0\ri0\sa40\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs24\alang1025 \ltrch\fcs0 \f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 \par }\pard\plain \ltrpar\qc \li0\ri0\sa40\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs24\alang1025 \ltrch\fcs0 \f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \ab\af1\afs32 \ltrch\fcs0 \b\fs32\insrsid9334144 Top copy accepted by patient:}{\rtlch\fcs1 \af1\afs32 \ltrch\fcs0 \fs32\insrsid9334144 }{\rtlch\fcs1 \ab\af1\afs32 \ltrch\fcs0 \b\fs32\insrsid9334144 yes/no}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\fs20\insrsid9334144 }{ \rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \fs20\insrsid9334144 (please ring)}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 \par }\pard\plain \ltrpar\s3\ql \li0\ri0\sa40\keepn\widctlpar\wrapdefault\faauto\outlinelevel2\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \ab\af1\afs24\alang1025 \ltrch\fcs0 \b\f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1\afs32 \ltrch\fcs0 \fs32\insrsid8418137 \par }{\rtlch\fcs1 \af1\afs32 \ltrch\fcs0 \fs32\insrsid9334144 Statement of patient}{\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \fs28\insrsid9334144 \tab }{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 \tab \tab \tab \tab Patient identifier/label \par }\pard\plain \ltrpar\s19\ql \li0\ri0\sa40\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs24\alang1025 \ltrch\fcs0 \f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 \par }\pard\plain \ltrpar\ql \li0\ri0\sa40\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs24\alang1025 \ltrch\fcs0 \f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid8418137 \par \par \par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 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 trea tment. If not, you will be offered a copy now. If you have any further questions, do ask \endash we are here to help you.}{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\insrsid9334144 }{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 You have the right to change your mind at any time, including after you have signed this form. \par \par }\pard \ltrpar\ql \fi-2268\li2268\ri0\sa40\widctlpar\wrapdefault\faauto\adjustright\rin0\lin2268\itap0 {\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\insrsid9334144 I agree}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 to the procedure or course of treatm ent described on this form. \par \par }\pard \ltrpar\ql \li0\ri0\sa40\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\insrsid9334144 I understand }{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 that you cannot give me a guarantee that a particular person will perform the procedure. The person will, however, have appropriate experience. \par }\pard\plain \ltrpar\s19\ql \li0\ri0\sa40\widctlpar\tx2268\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs24\alang1025 \ltrch\fcs0 \f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 \par }{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\insrsid9334144 I understand}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 that any procedure in addition to those described on thi s form will only be carried out if it is necessary to prevent serious harm to my health. \par \par }\pard\plain \ltrpar\ql \li0\ri0\sa40\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs24\alang1025 \ltrch\fcs0 \f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\insrsid9334144 I have been told}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 about additional procedures which may become necessary during my treatment. I have listed below any procedures }{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\insrsid9334144 which I do not wish to be carried out}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 without further discussion. \'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85 \par }\pard\plain \ltrpar\s3\ql \li0\ri0\sa40\keepn\widctlpar\wrapdefault\faauto\outlinelevel2\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \ab\af1\afs24\alang1025 \ltrch\fcs0 \b\f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \ab0\af1 \ltrch\fcs0 \b0\insrsid9334144 \'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85 \'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85.. \par }\pard\plain \ltrpar\ql \li0\ri0\sa40\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs24\alang1025 \ltrch\fcs0 \f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 \par Patient\rquote s signature \'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85..\tab Date\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85.. \par Name (PRINT) \'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85 \par \par }\pard\plain \ltrpar\s15\ql \li0\ri0\sa40\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \ab\af1\afs24\alang1025 \ltrch\fcs0 \b\f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 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). \par }\pard\plain \ltrpar\ql \li0\ri0\sa40\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs24\alang1025 \ltrch\fcs0 \f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 \par Signature \'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\tab Date \'85\'85\'85\'85\'85\'85\'85\'85..\'85.\'85\'85\'85 \par Name (PRINT) \'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85.\'85 \par \par }\pard\plain \ltrpar\s17\ql \li0\ri0\sa40\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs24\alang1025 \ltrch\fcs0 \f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\fs28\insrsid9334144 Confirmation of consent}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 (to be completed by a health professional when the patient is admitted for the procedure, if the patient has signed the form in advance) \par }\pard\plain \ltrpar\s19\ql \li0\ri0\sa40\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs24\alang1025 \ltrch\fcs0 \f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 \par }\pard\plain \ltrpar\ql \li0\ri0\sa40\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs24\alang1025 \ltrch\fcs0 \f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 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. \par \par Signed:\'85\'85.\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\tab \tab Date .. \'85\'85\'85\'85\'85\'85\'85\'85.\'85\'85\'85. \par Name (PRINT) \'85\'85\'85\'85\'85\'85\'85\'85\'85. \'85\'85\'85\tab \tab Job title \'85\'85.. \'85\'85\'85\'85\'85\'85\'85.\'85 \par \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\insrsid9334144 \page }{\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\fs28\insrsid9334144 Guidance to health professionals }{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \fs22\insrsid9334144 (to be read in conjunction with consent policy)}{\rtlch\fcs1 \ab\af1\afs22 \ltrch\fcs0 \b\fs22\insrsid9334144 \par }\pard\plain \ltrpar\s15\ql \li0\ri0\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \ab\af1\afs24\alang1025 \ltrch\fcs0 \b\f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \fs22\insrsid9334144 \par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs24\alang1025 \ltrch\fcs0 \f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \ab\af1\afs22 \ltrch\fcs0 \b\fs22\insrsid9334144 What a consent form is for}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \fs22\insrsid9334144 \par }{\rtlch\fcs1 \af1\afs16 \ltrch\fcs0 \fs16\insrsid9334144 \par }{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \fs22\insrsid9334144 This form documents the patient\rquote s agreement to go ahead with the investigation or treatment you have proposed. It is not a legal waiver \endash if patients, for example, do not receive enough information on which to base their decision, then the consent may not be valid, even though the form has been signed. Patients are also entitled to change their mind after signing the form, if they retain capacity to do so. The form should act as a n }{\rtlch\fcs1 \ai\af1\afs22 \ltrch\fcs0 \i\fs22\insrsid9334144 aide-memoire}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \fs22\insrsid9334144 to health professionals and patients, by providing a check-list of the kind of information patients should be offered, and by enabling the patient to have a written record of the main points discussed. In no way, however, should the written i nformation provided for the patient be regarded as a substitute for face-to-face discussions with the patient. \par \par }\pard\plain \ltrpar\s1\ql \li0\ri0\keepn\widctlpar\wrapdefault\faauto\outlinelevel0\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \ab\af1\afs28\alang1025 \ltrch\fcs0 \b\f1\fs28\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \fs22\insrsid9334144 The law on consent \par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs24\alang1025 \ltrch\fcs0 \f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \fs22\insrsid9334144 }{ \rtlch\fcs1 \af1\afs16 \ltrch\fcs0 \fs16\insrsid9334144 \par }{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \fs22\insrsid9334144 See the Department of Health\rquote s }{\rtlch\fcs1 \ai\af1\afs22 \ltrch\fcs0 \i\fs22\insrsid9334144 Reference guide to consent for examination or treatment}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \fs22\insrsid9334144 for a comprehensive summary of the law on consent (also available at }{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \fs22\insrsid9334144 HYPERLINK http://www.doh.gov.uk/consent }{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \fs22\insrsid12596056 {\*\datafield 00d0c9ea79f9bace118c8200aa004ba90b0200000017000000170000007700770077002e0064006f0068002e0067006f0076002e0075006b002f0063006f006e00730065006e0074000000e0c9ea79f9bace118c8200aa004ba90b3c00000068007400740070003a002f002f007700770077002e0064006f0068002e006700 6f0076002e0075006b002f0063006f006e00730065006e007400000000ffff000074}}}{\fldrslt {\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \cs21\fs22\ul\cf2\insrsid9334144 www.doh.gov.uk/consent}}}\sectd \marglsxn1134\margrsxn1134\margbsxn284\linex0\headery709\footery709\colsx709\endnhere\sectdefaultcl\sftnbj {\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \fs22\insrsid9334144 ). \par \par }\pard\plain \ltrpar\s3\ql \li0\ri0\keepn\widctlpar\wrapdefault\faauto\outlinelevel2\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \ab\af1\afs24\alang1025 \ltrch\fcs0 \b\f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \fs22\insrsid9334144 Who can give consent \par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs24\alang1025 \ltrch\fcs0 \f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1\afs16 \ltrch\fcs0 \fs16\insrsid9334144 \par }{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \fs22\insrsid9334144 {\*\xmlopen\xmlns2{\factoidname PersonName}}Eve{\*\xmlclose} ryone aged 16 or more is presumed to be competent to give consent for themselves, unless the opposite is demonstrated. If a child under the age of 16 has \'93sufficient understanding and intelligence to enable him or her to understand fully what is propos ed\'94, then he or she will be competent to give consent for himself or herself. Young people aged 16 and 17, and legally \lquote competent\rquote younger children, may therefore sign this form for themselves, but may like a parent to countersign as well. If the child is n ot able to give consent for himself or herself, some-one with parental responsibility may do so on their behalf and a separate form is available for this purpose. {\*\xmlopen\xmlns2{\factoidname PersonName}}Eve{\*\xmlclose} n where a child is able to give consent for himself or herself, you should always involve those with parental responsibility in the child\rquote s care, unless the child specifically asks you not to do so. If a patient is mentally competent to give consent but is physically unable to sign a form, you should complete this form as usual, and ask an ind ependent witness to confirm that the patient has given consent orally or non-verbally. \par }\pard\plain \ltrpar\s19\ql \li0\ri0\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs24\alang1025 \ltrch\fcs0 \f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \fs22\insrsid9334144 \par }\pard\plain \ltrpar\s3\ql \li0\ri0\keepn\widctlpar\wrapdefault\faauto\outlinelevel2\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \ab\af1\afs24\alang1025 \ltrch\fcs0 \b\f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \fs22\insrsid9334144 When NOT to use this form \par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs24\alang1025 \ltrch\fcs0 \f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1\afs16 \ltrch\fcs0 \fs16\insrsid9334144 \par }\pard\plain \ltrpar\s18\ql \li0\ri0\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs22\alang1025 \ltrch\fcs0 \f1\fs22\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 If the patient is 18 or over and is not legally competent to give consent, you should use form 4 (form for adults who are unable to consent to investigation or treatment) instead of this form. A patient will not be legally competent to give consent if: \par {\pntext\pard\plain\ltrpar \s18 \rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f3\fs22\insrsid9334144 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard \ltrpar\s18\ql \fi-360\li420\ri0\widctlpar\jclisttab\tx420\wrapdefault{\*\pn \pnlvlblt\ilvl0\ls11\pnrnot0 \pnf3\pnstart1\pnindent360\pnsp120\pnhang {\pntxtb \'b7}}\faauto\ls11\adjustright\rin0\lin420\itap0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 they are unable to comprehend and retain information material to the decision and/or \par {\pntext\pard\plain\ltrpar \s18 \rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f3\fs22\insrsid9334144 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard \ltrpar\s18\ql \fi-360\li420\ri0\widctlpar\jclisttab\tx420\wrapdefault{\*\pn \pnlvlblt\ilvl0\ls11\pnrnot0 \pnf3\pnstart1\pnindent360\pnsp120\pnhang {\pntxtb \'b7}}\faauto\ls11\adjustright\rin0\lin420\itap0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 they are unable to weigh and use this information in coming to a decision. \par }\pard \ltrpar\s18\ql \li0\ri0\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 You should always take all reasonable steps (for example involving more specialist colleagues) to support a patient in making their own decision, before concluding that they are unable to do so. \par Relatives }{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\insrsid9334144 cannot}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 be asked to sign this form on behalf of an adult who is not legally competent to consent for himself or herself. \par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs24\alang1025 \ltrch\fcs0 \f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \fs22\insrsid9334144 \par }\pard\plain \ltrpar\s3\ql \li0\ri0\keepn\widctlpar\wrapdefault\faauto\outlinelevel2\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \ab\af1\afs24\alang1025 \ltrch\fcs0 \b\f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \fs22\insrsid9334144 Information \par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs24\alang1025 \ltrch\fcs0 \f1\fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1\afs16 \ltrch\fcs0 \fs16\insrsid9334144 \par }{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \fs22\insrsid9334144 Information about what the treatment will involve, its benefits and risks (including side-effects and complications) and the alternatives to the par ticular procedure proposed, is crucial for patients when making up their minds. The courts have stated that patients should be told about \lquote significant risks which would affect the judgement of a reasonable patient\rquote . \lquote Significant \rquote has not been legally defined, but the GMC requires doctors to tell patients about \lquote serious or frequently occurring\rquote risks. In addition if patients make clear they have particular concerns about certain kinds of risk, you should make sure they are informed about these risks, even if they are very small or rare. You should always answer questions honestly. Sometimes, patients may make it clear that they do not want to have any information about the options, but want you to decide on their behalf. In such circumstances, you should do your best to ensure that the patient receives at least very basic information about what is proposed. Where information is refused, you should document this on page 2 of the form or in the patient\rquote s notes.}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid9334144 \par }}