Form HWZ0803S "Consent Form 1 - Patient Agreement to Investigation or Treatment" - United Kingdom

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Download Form HWZ0803S "Consent Form 1 - Patient Agreement to Investigation or Treatment" - United Kingdom

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HT_0709_consent 1
Statement of patient
Please read this form carefully. If your treatment has been planned in advance, you should already have your
own copy, which describes the benefits and risks of the proposed treatment. If not, you will be offered a copy
1
Consent Form
now. If you have any further questions, do ask - we are here to help. You have the right to change your mind at
Patient Agreement to Investigation or Treatment
any time, including after you have signed this form.
I agree to the procedure or course of treatment described on this form.
Patient details (or pre-printed label)
I understand that you cannot give me a guarantee that a particular person will perform the procedure. The
Patient’s surname/family name ............................................... Patient’s first names ....................................................
person will, however, have appropriate experience.
Date of Birth............................................................................. Male
Female
NHS number ............................................................................. PID ................................................................................
I understand that I will have the opportunity to discuss the details of anaesthesia with an anaesthetist before
Responsible health professional.......................................................................................................................................
the procedure, unless the urgency of my situation prevents this (this only applies to patients having general
Job title ..................................................................................... Registration number...................................................
anaesthesia).
Special requirements.........................................................................................................................................................
(eg other language/other communication method)
I understand that any procedure in addition to those described on this form will only be carried out if it is
Name of proposed procedure or course of treatment
(include brief explanation if medical
necessary to save my life or to prevent serious harm to my health.
term not clear): .................................................................................................................................................................
I have been told about additional procedures which may become necessary during my treatment. I have listed
...........................................................................................................................................................................................
here any procedures which I do not wish to be carried out without further discussion, even if I become at risk of
Statement of health professional
death:.................................................................................................................................................................................
(to be filled in by health professional with appropriate
...........................................................................................................................................................................................
knowledge of proposed procedure, as specified in consent policy and delegated consent policy)
I have read and understood the guidance to health professionals overleaf.
I consent/do not consent to the removal of my tissue and/or blood products during this operation and
I consent/do not consent to its use for (tick as applicable):
I have explained the procedure to the patient, in particular, I have explained:
Research in connection with disorders and/or the functioning of the human body
The intended benefits: ......................................................................................................................................................
Obtaining scientific or medical information about a living or deceased person which may be relevant to
.............................................................................................................................................................................................
any other person (including a future person)
.............................................................................................................................................................................................
Patient’s signature................................................................................................Date......................................................
The significant, unavoidable or frequently occurring risks:............................................................................................
Name (PRINT).................................................................................................................... . ..................................................
............................................................................................................................................................................................
............................................................................................................................................................................................
A witness should sign below if the patient is unable to sign but has indicated his or her consent. Young people
Any extra procedures which may become necessary during the procedure:
/ children may also like a parent to sign here.
Blood transfusion ................................................................................................................................................
Signed....................................................................................................................Date......................................................
Name (PRINT).................................................................................................................... . ..................................................
Other procedures (please specify):......................................................................................................................
..............................................................................................................................................................................
Confirmation of consent
I have also discussed what the procedure is likely to involve, the benefits and risks of any available alternative
(be completed by a health professional and the patient when the patient is
treatments (including no treatment) and any particular concerns of this patient.
admitted for the procedure, if the patient has signed the form in advance)
The following leaflet/CD/DVD has been provided..............................................................................................
On behalf of the team treating the patient, I have discussed the treatment with the patient and answered any
This procedure will involve:
further questions or concerns. I have also confirmed with the patient that she/he has made an informed decision
General anaesthesia
Local anaesthesia
Sedation
and wishes to go ahead.
Signed ................................................................................................................. Date ....................................................
Name (PRINT)...................................................................................................... Job Title..............................................
Health Professional
Signed ................................................................................................................. Date ....................................................
Statement of interpreter
(where appropriate)
Name (PRINT)...................................................................................................... Job Title..............................................
I have interpreted the information above to the patient to the best of my ability and in a way in which I believe
Patient
she/he can understand.
Signed ................................................................................................................. Date ....................................................
Signed .......................................................................................................................Date..................................................
Name (PRINT) ....................................................................................................................................................................
Name (PRINT)......................................................................................................................................................................
Important notes: (tick if applicable)
See also advanced decision to refuse treatment/living will (e.g. Jehovah’s witness form)
Patient has withdrawn consent, patient to sign and date here to confirm.....................................................
Copy accepted by patient: yes / no (please ring)
YELLOW COPY: CASE NOTES
WHITE COPY: PATIENT
HWZ0803S
HT_0709_consent 1
Statement of patient
Please read this form carefully. If your treatment has been planned in advance, you should already have your
own copy, which describes the benefits and risks of the proposed treatment. If not, you will be offered a copy
1
Consent Form
now. If you have any further questions, do ask - we are here to help. You have the right to change your mind at
Patient Agreement to Investigation or Treatment
any time, including after you have signed this form.
I agree to the procedure or course of treatment described on this form.
Patient details (or pre-printed label)
I understand that you cannot give me a guarantee that a particular person will perform the procedure. The
Patient’s surname/family name ............................................... Patient’s first names ....................................................
person will, however, have appropriate experience.
Date of Birth............................................................................. Male
Female
NHS number ............................................................................. PID ................................................................................
I understand that I will have the opportunity to discuss the details of anaesthesia with an anaesthetist before
Responsible health professional.......................................................................................................................................
the procedure, unless the urgency of my situation prevents this (this only applies to patients having general
Job title ..................................................................................... Registration number...................................................
anaesthesia).
Special requirements.........................................................................................................................................................
(eg other language/other communication method)
I understand that any procedure in addition to those described on this form will only be carried out if it is
Name of proposed procedure or course of treatment
(include brief explanation if medical
necessary to save my life or to prevent serious harm to my health.
term not clear): .................................................................................................................................................................
I have been told about additional procedures which may become necessary during my treatment. I have listed
...........................................................................................................................................................................................
here any procedures which I do not wish to be carried out without further discussion, even if I become at risk of
Statement of health professional
death:.................................................................................................................................................................................
(to be filled in by health professional with appropriate
...........................................................................................................................................................................................
knowledge of proposed procedure, as specified in consent policy and delegated consent policy)
I have read and understood the guidance to health professionals overleaf.
I consent/do not consent to the removal of my tissue and/or blood products during this operation and
I consent/do not consent to its use for (tick as applicable):
I have explained the procedure to the patient, in particular, I have explained:
Research in connection with disorders and/or the functioning of the human body
The intended benefits: ......................................................................................................................................................
Obtaining scientific or medical information about a living or deceased person which may be relevant to
.............................................................................................................................................................................................
any other person (including a future person)
.............................................................................................................................................................................................
Patient’s signature................................................................................................Date......................................................
The significant, unavoidable or frequently occurring risks:............................................................................................
Name (PRINT).................................................................................................................... . ..................................................
............................................................................................................................................................................................
............................................................................................................................................................................................
A witness should sign below if the patient is unable to sign but has indicated his or her consent. Young people
Any extra procedures which may become necessary during the procedure:
/ children may also like a parent to sign here.
Blood transfusion ................................................................................................................................................
Signed....................................................................................................................Date......................................................
Name (PRINT).................................................................................................................... . ..................................................
Other procedures (please specify):......................................................................................................................
..............................................................................................................................................................................
Confirmation of consent
I have also discussed what the procedure is likely to involve, the benefits and risks of any available alternative
(be completed by a health professional and the patient when the patient is
treatments (including no treatment) and any particular concerns of this patient.
admitted for the procedure, if the patient has signed the form in advance)
The following leaflet/CD/DVD has been provided..............................................................................................
On behalf of the team treating the patient, I have discussed the treatment with the patient and answered any
This procedure will involve:
further questions or concerns. I have also confirmed with the patient that she/he has made an informed decision
General anaesthesia
Local anaesthesia
Sedation
and wishes to go ahead.
Signed ................................................................................................................. Date ....................................................
Name (PRINT)...................................................................................................... Job Title..............................................
Health Professional
Signed ................................................................................................................. Date ....................................................
Statement of interpreter
(where appropriate)
Name (PRINT)...................................................................................................... Job Title..............................................
I have interpreted the information above to the patient to the best of my ability and in a way in which I believe
Patient
she/he can understand.
Signed ................................................................................................................. Date ....................................................
Signed .......................................................................................................................Date..................................................
Name (PRINT) ....................................................................................................................................................................
Name (PRINT)......................................................................................................................................................................
Important notes: (tick if applicable)
See also advanced decision to refuse treatment/living will (e.g. Jehovah’s witness form)
Patient has withdrawn consent, patient to sign and date here to confirm.....................................................
Copy accepted by patient: yes / no (please ring)
YELLOW COPY: CASE NOTES
WHITE COPY: PATIENT
HWZ0803S
Guidance to health professionals
(to be read in conjunction with The Consent to Treatment or Examination
policy)
When NOT to use this form
What a consent form is for
When a patient is below 18 and does not have the capacity to consent, you should
This form documents the patient’s agreement to go ahead with the investigation or
use consent form 2 (i.e. Parental (or person with parental responsibility) agreement to
treatment you have proposed. It is not a legal waiver - if patients, for example, do not
investigation or treatment for a child or young person). A patient lacks the capacity
receive enough information on which to base their decision, then the consent may not
to consent to the proposed treatment or investigation if they have an impairment of
be valid, even though the form has been signed. Patients are also entitled to change
the mind or brain or disturbance affecting the way their mind or brain works and they
their mind after signing the form, if they retain capacity to do so. The form should
cannot:
act as an aide-memoire to health professionals and patients, by providing a check-list
• understand the information about the decision to be made
of the kind of information patients should be offered, and by enabling the patient
• retain that information
to have a written record of the main points discussed. In no way, however, should the
• use or weigh that information as part of the process of making a decision
written information provided for the patient be regarded as a substitute for face-to-
• communicate their decision (by talking, using sign language or any other means)
face discussions with the patient.
You should always take all reasonable steps (e.g. involving more specialist colleagues)
to support a patient in making their own decision, before concluding that they lack
The law on consent
the capacity to do so.
Relatives cannot be asked to sign a form on behalf of an adult who lacks capacity to
The process of taking consent is underpinned by the common law, the Human Rights
consent for themselves unless they have been given the authority to do so under a
Act 1998 and the Mental Capacity Act 2005. All staff involved in providing care to
Lasting Power of Attorney or as a Court Appointed Deputy.
patients must be familiar with the Consent to Treatment or Examination policy.
Information
More information on consent and the legislation behind it can be found in the
Department of Health’s Reference Guide to Consent for Examination or Treatment at
Information about what the treatment will involve, its benefits and risks (including
http://www.dh.gov.uk or the Office of the Public Guardian at
side-effects and complications) and the alternatives to this procedure proposed is
http://www.publicguardian.gov.uk/.
crucial for patients when making up their minds. The courts have stated that patients
should be told about ‘significant’ risks which would affect the judgement of a
reasonable patient. ‘Significant’ has not been legally defined, but the GMC requires
Who can give consent
doctors to tell patients about significant, unavoidable and frequently occurring risks.
In addition if patients make it clear they have particular concerns about certain kinds
Everyone aged 16 or more is presumed to be competent to give consent for
of risk, you should make sure they are informed about these risks, even if they are
themselves, unless the opposite is demonstrated. If a child under the age of 16 has
very small or rare. You should always answer questions honestly. Sometimes, patients
“sufficient understanding and intelligence to enable him or her to understand fully
may make it clear that they do not want to have any information about the options,
what is proposed”, then he or she will be competent to give consent for himself or
but want you to decide on their behalf. In such circumstances, you should do your best
herself. Young people aged 16 and 17, and legally ‘competent’ younger children, may
to ensure that the patient receives at least the very basic information about what is
therefore sign this form for themselves, but may like a parent to counter sign as well.
proposed. Where information is refused, you should document this on this form and
However even where a child is able to give consent for himself or herself, you should
in the patient’s medical records.
always involve those with parental responsibility in the child’s care, unless the child
If consent is sought for the use of tissue/blood products from the patient for one or
specifically asks you not to do so. If a patient is mentally competent to give consent
more of the purposes identified in the consent form, information should be given to
but physically unable to sign a form, you should complete this form as usual, and ask
the patient about the nature and purpose of what is proposed so that the patient is
an independent witness to confirm that the patient has given consent.
able to make an informed decision. The patient should be told of any ‘significant’ risks
inherent in the way the tissue/blood products will be obtained, how the tissue/blood
products will be used and any risks or possible implications of its use. When taking
consent for the use of tissue/blood products, you should comply with the Human Tissue
Authority Code of Practice on Consent.
HT_0709_consent 1
Statement of patient
Please read this form carefully. If your treatment has been planned in advance, you should already have your
own copy, which describes the benefits and risks of the proposed treatment. If not, you will be offered a copy
1
Consent Form
now. If you have any further questions, do ask - we are here to help. You have the right to change your mind at
Patient Agreement to Investigation or Treatment
any time, including after you have signed this form.
I agree to the procedure or course of treatment described on this form.
Patient details (or pre-printed label)
I understand that you cannot give me a guarantee that a particular person will perform the procedure. The
Patient’s surname/family name ............................................... Patient’s first names ....................................................
person will, however, have appropriate experience.
Date of Birth............................................................................. Male
Female
NHS number ............................................................................. PID ................................................................................
I understand that I will have the opportunity to discuss the details of anaesthesia with an anaesthetist before
Responsible health professional.......................................................................................................................................
the procedure, unless the urgency of my situation prevents this (this only applies to patients having general
Job title ..................................................................................... Registration number...................................................
anaesthesia).
Special requirements.........................................................................................................................................................
(eg other language/other communication method)
I understand that any procedure in addition to those described on this form will only be carried out if it is
Name of proposed procedure or course of treatment
(include brief explanation if medical
necessary to save my life or to prevent serious harm to my health.
term not clear): .................................................................................................................................................................
I have been told about additional procedures which may become necessary during my treatment. I have listed
...........................................................................................................................................................................................
here any procedures which I do not wish to be carried out without further discussion, even if I become at risk of
Statement of health professional
death:.................................................................................................................................................................................
(to be filled in by health professional with appropriate
...........................................................................................................................................................................................
knowledge of proposed procedure, as specified in consent policy and delegated consent policy)
I have read and understood the guidance to health professionals overleaf.
I consent/do not consent to the removal of my tissue and/or blood products during this operation and
I consent/do not consent to its use for (tick as applicable):
I have explained the procedure to the patient, in particular, I have explained:
Research in connection with disorders and/or the functioning of the human body
The intended benefits: ......................................................................................................................................................
Obtaining scientific or medical information about a living or deceased person which may be relevant to
.............................................................................................................................................................................................
any other person (including a future person)
.............................................................................................................................................................................................
Patient’s signature................................................................................................Date......................................................
The significant, unavoidable or frequently occurring risks:............................................................................................
Name (PRINT).................................................................................................................... . ..................................................
............................................................................................................................................................................................
............................................................................................................................................................................................
A witness should sign below if the patient is unable to sign but has indicated his or her consent. Young people
Any extra procedures which may become necessary during the procedure:
/ children may also like a parent to sign here.
Blood transfusion ................................................................................................................................................
Signed....................................................................................................................Date......................................................
Name (PRINT).................................................................................................................... . ..................................................
Other procedures (please specify):......................................................................................................................
..............................................................................................................................................................................
Confirmation of consent
I have also discussed what the procedure is likely to involve, the benefits and risks of any available alternative
(be completed by a health professional and the patient when the patient is
treatments (including no treatment) and any particular concerns of this patient.
admitted for the procedure, if the patient has signed the form in advance)
The following leaflet/CD/DVD has been provided..............................................................................................
On behalf of the team treating the patient, I have discussed the treatment with the patient and answered any
This procedure will involve:
further questions or concerns. I have also confirmed with the patient that she/he has made an informed decision
General anaesthesia
Local anaesthesia
Sedation
and wishes to go ahead.
Signed ................................................................................................................. Date ....................................................
Name (PRINT)...................................................................................................... Job Title..............................................
Health Professional
Signed ................................................................................................................. Date ....................................................
Statement of interpreter
(where appropriate)
Name (PRINT)...................................................................................................... Job Title..............................................
I have interpreted the information above to the patient to the best of my ability and in a way in which I believe
Patient
she/he can understand.
Signed ................................................................................................................. Date ....................................................
Signed .......................................................................................................................Date..................................................
Name (PRINT) ....................................................................................................................................................................
Name (PRINT)......................................................................................................................................................................
Important notes: (tick if applicable)
See also advanced decision to refuse treatment/living will (e.g. Jehovah’s witness form)
Patient has withdrawn consent, patient to sign and date here to confirm.....................................................
Copy accepted by patient: yes / no (please ring)
YELLOW COPY: CASE NOTES
WHITE COPY: PATIENT
HWZ0803S
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