Statement of health professional. I have explained the procedure to the patient. In particular, I have explained:
Statement of health professional. I can confirm that the patient is aware of the benefits and adverse effects of this procedure as outlined above. Signed Date NAME
Statement of health professional. I have explained the procedure to the patient, in particular, I have explained: The intended benefit: Symptoms relief +/- diagnosis. The significant, unavoidable, or frequently occurring risks • Allergic reaction. • Postoperative pain, discomfort, redness and swelling. These may rarely persist long term. • Bleeding and bruising that may necessitate further treatment. • Unfavourable Scarring (Hypertrophic scars and Keloid scars) and dyspigmentation (change of skin colour). • Postoperative infection requiring additional treatment. • Injury to nerves resulting in numbness or tingling or muscle weakness. This may persist months, or rarely, permanently. • Incomplete resolution or recurrence, the lesion may come back. • Asymmetry and/ or deformity. • Further procedures to address the original complaint or the side effects. Any extra procedures which may become necessary during the procedure. 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.
Statement of health professional. I have explained the procedure to the patient/parent. In particular, I have explained: The intended benefits: ☐ For diagnosis ☐ To remove skin cancer ☐ Other benefit: .............................……………..………………………………………………....... Serious or frequently occurring risks: Common (most patients, but usually mild or minor effects) ☐ Scar ☐ Discomfort ☐ Bruising & Swelling ☐ Numbness Uncommon (usually fewer than 1 patient in every 30 treated) ☐ Bleeding (after going home) ☐ Wound infection ☐ Incomplete removal of tumour (fewer than 1 in 50 if Mohs) ☐ Recurrence Rare (usually fewer than 1 patient in every 100 treated) ☐ Permanent numbness/altered sensation ☐ Nerve damage to muscle ☐ Unacceptable scar needing another (not expected) operation Other: .……………………….………………………………………………………………….... 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 patient/parent concerns. The patient/parent appears to understand. I have invited questions and these: ☐ were answered ☐ none were asked. A leaflet/video or web link was provided: ☐ Guide to Mohs micrographic surgery (NBT) Signed .…………………………………… Date ……...……………………………..... Name (PRINT) Xx Xxxx Xxxx Job title Consultant Dermatologist Statement of interpreter (where necessary) I have interpreted the information above to the patient/parent to the best of my ability and in a way in which I believe s/he/they can understand. Signed ……………….……….Date…….…………..Name (PRINT)………………………….. Statement of patient/person with parental responsibility for patient I understand and agree to the procedure described above. The procedure, alternatives and risks were explained to me in clear terms. Any questions I had were answered to my satisfaction. I was encouraged to read a leaflet/link about the procedure that I was given and I intend to do so. I understand that the procedure will involve local anaesthesia (an injection into the skin). Signature ………………………………………. Date ……………………………..……………… Name (PRINT) ………………………………… Relationship to patient ………………………… Confirmation of consent (to be completed by a health professional when the patient is admitted for the procedure, if the patient/parent has signed the form in advance) I have confirmed that the patient/parent has no further questions and wishes the procedure to go ahead. Signed: …………………………………… Date ……... ……………………………. Name (PRINT) ………………………..……….. Job title ………………………………… Copy accepted by patient:...
Statement of health professional. I have explained the procedure to the patient, the intended benefits of the procedure: To create access for haemodialysis. Any serious or frequently occurring risks from the procedures including those specific to the patient: Failure to mature, thrombosis or stenosis of fistula, mild to moderate steal syndrome, aneurysm of fistula, minor nerve damage, severe steal syndrome, major nerve damage, ischaemic neuropathy, compartment syndrome, bleeding, infection and deep vein thrombosis Any extra procedures that might become necessary during the procedure such as blood transfusion or other procedure (please specify) I have discussed what the treatment/procedure is likely to involve, the benefits and risks of any available alternative treatments (including no treatment) and any particular concerns of this patient. The following information leaflet has been provided: Arteriovenous Fistula as access for Haemodialysis This procedure will involve: ❑ General or Regional Anaesthesia ❑ Local Anaesthesia ❑ Sedation Health Professional’s Signature: Date: Name (PRINT): Job Title: Statement from the Patient Please read this form carefully. If your treatment has been planned, you should already have a copy, which describes the benefits and risks of the proposed treatment. If not, you will be offered one. Do ask if you have any further questions. The staff at Addenbrooke’s are here to help you. You have the right to change your mind at any time before the procedure is undertaken, including after you have signed this form. Training doctors and other health professionals is essential to the continuation of the Health Service and improving the quality of care. Your treatment may provide an important opportunity for such training, where necessary under the careful supervision of a senior doctor. You may, however, decline to be involved in the formal training of medical and other students without this adversely affecting your care and treatment. Please read the following 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 you cannot give me a guarantee that a particular person will perform the procedure. The person undertaking the procedure will, however, have appropriate experience. I understand that any procedure in addition to those described on this form will only be...
