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1. Patient Information: Patient's personal details, identification, and contact information
2. Healthcare Provider Information: Details of the medical facility and treating healthcare professionals
3. Procedure Description: Detailed explanation of the medical procedure or treatment, including purpose and nature of the procedure
4. Risks and Benefits: Comprehensive list of potential risks, complications, and expected benefits of the procedure
5. Alternative Treatments: Information about alternative treatment options available to the patient
6. Declaration of Consent: Formal statement of patient's voluntary agreement to proceed with the procedure, acknowledgment of understanding
7. Data Protection Notice: Information about how patient's personal and medical data will be collected, used, and protected
8. Signatures: Signature blocks for patient, healthcare provider, and witnesses
1. Interpreter Declaration: Declaration section for cases where consent discussions involve an interpreter for non-English speaking patients
2. Proxy Decision Maker Authorization: Section for documenting details and authority of proxy decision maker when patient lacks mental capacity
3. Clinical Photography Consent: Additional consent for medical photography or recording of the procedure
4. Blood Products Authorization: Specific consent for administration of blood products if required during treatment
5. Teaching Institution Disclosure: Additional disclosures for procedures performed at teaching institutions involving medical students or trainees
1. Schedule A - Procedure Information Sheet: Detailed medical information about the specific procedure including technical details and preparation requirements
2. Schedule B - Post-Procedure Care Instructions: Comprehensive guidelines for after-care, recovery process, and follow-up appointments
3. Schedule C - Cost Schedule: Detailed breakdown of procedure costs, payment terms, and insurance information
4. Schedule D - Emergency Contact Form: Form for recording emergency contact information and their relationship to the patient
5. Schedule E - Medication List: List of current medications, allergies, and potential drug interactions
Medical Procedure
Healthcare Provider
Patient
Treatment
Medical Facility
Emergency
Capacity
Personal Data
Medical Records
Next of Kin
Proxy Decision Maker
Material Risks
Side Effects
Alternative Treatment
Confidential Information
Medical Emergency
Witness
Informed Consent
Healthcare Institution
Clinical Photography
Medical Team
Attending Physician
Treatment Plan
Revocation
Healthcare Provider Details
Procedure Description
Risks and Benefits
Alternative Treatments
Consent Declaration
Data Protection
Confidentiality
Emergency Procedures
Revocation Rights
Photography and Recording
Cost Disclosure
Information Access
Medical Records
Patient Rights
Liability
Witness Attestation
Language Declaration
Mental Capacity
Research Use
Quality Assurance
Information Sharing
Treatment Refusal
Emergency Contacts
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