Minor Surgery Consent Form

Date: *

Patient Details

Patient Name: *

Date of Birth: *

Address: *

Postcode: *

Email: *

Contact Number: *

Surgery / Treatment

Procedure: *

Parental Consent

Is the patient 18 or over? *

Legal Guardian Name: *

Legal Guardian Number: *

If you have any further questions, do ask - we are here to help. You and your child have the right to change your mind at any time, including after you have signed this form.

I agree to the procedure or course of treatment described on this form and I confirm that I have ‘parental responsibility’ for this child.

I understand that you cannot give me a guarantee that a particular person will perform the procedure. The person will, however, have appropriate experience.

I understand that where applicable, my child and 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 children having general anaesthesia.)

I understand that any procedure in addition to those described on this form will only be carried out if it is necessary to save the life of my child or to prevent serious harm to his or her health.

Parent/Guardian Signature: *

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Patient Consent

The health professional has explained the following to me:

The intended benefits of the surgery/treatment.
Serious or frequently occurring risks.
Any extra procedures which may become necessary during the procedure.
What the procedure is likely to involve, the benefits and risks of any available, alternative treatments (including no treatment) and any particular concerns I had.

List any procedures which you do not wish to be carried out without further discussion:

By my electronic signature below, I acknowledge that I have read and fully understand this agreement and all the information detailed above.

Patient Signature: *

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Lead Health Professional to complete

Lead Health Professional Name: *

Procedure Details: *

On behalf of the team treating the patient, I have discussed the treatment with the patient and parent/person with parental responsibility and answered any further questions or concerns. I have also confirmed with the parents/person with parental responsibility that she/he has made an informed decision and wishes the patient to undergo the procedure.

On behalf of the team treating the patient, I have discussed the treatment with the patient and answered any further questions or concerns. I have also confirmed with the patient that she/he has made an informed decision and wishes to undergo the procedure.

Lead Health Professional Signature: *

Tap or click on the signature above to sign

Data Protection and Privacy

We are committed to protecting your privacy. We take special precautions with your sensitive personal data and we will process your data lawfully and as described. We only process the data we need for as long as we need to and we respect all of your rights under GDPR. We will never sell, share or otherwise abuse your data. You can contact us at anytime to request your data, change your preferences or request that your data be deleted. GDPR is the European privacy law designed to protect you and give you control of your data.