1. Interpreter Declaration: Required when the patient's primary language is not English, including interpreter details and confirmation of accurate translation

2. Alternative Treatments: Section listing any alternative treatments discussed and considered

3. Emergency Contact Details: Contact information for next of kin or emergency contact, particularly important in high-risk refusal cases

4. Time-Limited Refusal: Used when the refusal applies only for a specific time period rather than indefinitely

5. Religious or Cultural Grounds: Specific section for documenting religious or cultural reasons for refusal when applicable

6. Advance Healthcare Directive Reference: Required when the refusal is related to or impacts existing advance healthcare directives

1. Schedule A - Detailed Medical Information: Technical description of the refused treatment/procedure and its standard risks and benefits

2. Schedule B - Patient Information Leaflet: Copy of any information materials provided to the patient regarding the refused treatment

3. Appendix 1 - Capacity Assessment: Documentation of capacity assessment if conducted

4. Appendix 2 - Additional Medical Notes: Relevant medical history or notes pertaining to the treatment decision