Patient agreement to investigation or treatment



Download 9.12 Kb.
Date conversion31.01.2017
Size9.12 Kb.

Patient agreement to investigation or treatment

Patient’s surname/family name..…………………………………………………………...

Patient’s first names .…………………………………………………………………….….

Date of birth ………………………………………………………………………………….

NHS number (or other identifier)……………………………………………………….…..

 Male  Female

Name of procedure/treatment:Excision of pyogenic granuloma under local anaesthetic



Statement of health professional: (to be filled in by appropriate health professional.)

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


Intended benefits: Removal of lesion, enable diagnosis and to aid relief of symptoms.

Serious or frequently occurring risks: Infection, pain, bleeding, persistent scar, nerve injury, tendon injury, blood vessel injury, cyst recurrence, decreased range of motion, need for further surgery.

I have also discussed any available alternative treatments (including no treatment) and any particular concerns expressed by this patient.

The following leaflet has been provided ……………….…………………………………………

I consider the patient to be competent based upon his/her ability to believe, understand, retain and weigh up the information provided to him/her and so reach a decision voluntarily

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

Name (PRINT) ………………………. ………. Job title …….. ………………….…….


Statement of patient


I have read above and I agree to the procedure/course of treatment described on this form

Patient’s signature …………………………… Date…………………………………...

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

Confirmation of consent (to be completed by the health professional when the patient attends for the procedure, if the patient has signed the form in advance)

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

Name (PRINT) ………………………. ………. Job title …….. ………………….…….

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) …………………..…………………………………………………………………..



www.primarycareforms.com


The database is protected by copyright ©dentisty.org 2016
send message

    Main page