Liverpool Community Health NHS Trust Consent Form 3 Patient / Parental agreement to an investigation or treatment (where consciousness is not impaired) Patient details (or pre-printed label) surname / family name Patient‟s ..………………………………. first names Patient‟s ………………………………... Date of birth ………………………………... Responsible health professional ………………………………... Job title ………………………………... NHS number (or other identifier) ………………………………... Male Female Special requirements ………………………………... (e.g. other language/other communication method) To be retained in notes patient’s
Liverpool Community Health NHS Trust Consent Form 3 Patient / Parental agreement to an investigation or treatment (where consciousness is not impaired) Patient details (or pre-printed label) Patient‟s surname / family name ..………………………………. Patient‟s first names ………………………………... Date of birth ………………………………... Responsible health professional ………………………………... Job title ………………………………... NHS number (or other identifier) ………………………………... Male Female Special requirements ………………………………... (e.g. other language/other communication method) To be retained in patient’s notes