This is an HTML version of an attachment to the Freedom of Information request 'Outpatient hysteroscopy/biopsy - Pain Control and Patient Choice'.

[NHS organisation name] consent form 3
Patient identifier/label
Patient/parental agreement to investigation or treatment
(procedures where consciousness not impaired)
Name of procedure (include brief explanation if medical term not clear)
……………………………………………………………………………………………………………
………………………………………………………………………………………………...
Statement of health professional  (to be filled in by health professional with appropriate
knowledge of proposed procedure, as specified in consent policy)
I have explained the procedure to the patient/parent. In particular, I have explained:
The intended benefits …………………………………………………………………….……………
…………………………………………………………………………………………………………….
…………………………………………………………………………………………………………….
Serious or frequently occurring risks:……………………………………………………….………..
...………………………………………………………………………………………………………….
………………………………….…………………………………………………………………………
I have also discussed what the procedure is likely to involve, the benefits and risks of any
available alternative treatments (including no treatment) and any particular concerns of those
involved.
  The following leaflet/tape has been provided …………………………………………….……..
Signed:
.…………………………………… Date ……... ……………………………………..
Name (PRINT) ………………………. ……….
Job title ………………………………………….
Statement of interpreter (where appropriate)
I have interpreted the information above to the patient/parent to the best of my ability and in a
way in which I believe s/he/they can understand.
Signed ……………….……….Date…….…………..Name (PRINT)…………….…………………..
Statement of patient/person with parental responsibility for patient
I agree
 to the procedure described above.
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 the procedure will/will not involve local anaesthesia.
Signature ……………………………………….
Date ……………………………..………………
Name (PRINT) …………………………………
Relationship to patient …………………………
Confirmation of consent (to be completed by a health professional when the patient is admitted for
the procedure, if the patient/parent has signed the form in advance)
I have confirmed that the patient/parent has no further questions and wishes the procedure to
go ahead.
Signed:
……………………………………
Date ……... …………………………….
Name (PRINT) ………………………..………..
Job title …………………………………
Top copy accepted by patient: yes/no (please ring)

Guidance to health professionals (to be read in conjunction with consent policy)
This form
This form documents the patient’s agreement (or that of a person with parental responsibility for the
patient) to go ahead with the investigation or treatment you have proposed. It is only designed for
procedures where the patient is expected to remain alert throughout and where an
anaesthetist is not involved in their care: for example for drug therapy where written consent
is deemed appropriate.
  In other circumstances you should use either form 1 (for adults/competent
children) or form 2 (parental consent for children/young people) as appropriate.
Consent forms are not legal waivers – if patients, for example, do not receive enough information on
which to base their decision, then the consent may not be valid, even though the form has been
signed.  Patients also have every right to change their mind after signing the form.
Who can give consent
Everyone aged 16 or more is presumed to be competent to give consent for themselves, unless the
opposite is demonstrated. If a child under the age of 16 has “sufficient understanding and intelligence
to enable him or her to understand fully what is proposed”, then he or she will be competent to give
consent for himself or herself.  Young people aged 16 and 17, and legally ‘competent’ younger
children, may therefore sign this form for themselves, if they wish.  If the child is not able to give
consent for himself or herself, some-one with parental responsibility may do so on their behalf.  Even
where a child is able to give consent for himself or herself, you should always involve those with
parental responsibility in the child’s care, unless the child specifically asks you not to do so.  If a
patient is mentally competent to give consent but is physically unable to sign a form, you should
complete this form as usual, and ask an independent witness to confirm that the patient has given
consent orally or non-verbally.
When NOT to use this form (see also ‘This form’ above)
If the patient is 18 or over and is not legally competent to give consent, you should use form 4 (form
for adults who are unable to consent to investigation or treatment) instead of this form.  A patient will
not be legally competent to give consent if:
•  they are unable to comprehend and retain information material to the decision and/or
•  they are unable to weigh and use this information in coming to a decision.
You should always take all reasonable steps (for example involving more specialist colleagues) to
support a patient in making their own decision, before concluding that they are unable to do so.
Relatives cannot be asked to sign this form on behalf of an adult who is not legally competent to
consent for himself or herself.
Information
Information about what the treatment will involve, its benefits and risks (including side-effects and
complications) and the alternatives to the particular procedure proposed, is crucial for patients when
making up their minds about treatment.  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 doctors to tell patients about ‘serious or frequently occurring’
risks.  In addition if patients make clear they have particular concerns about certain kinds of risk, you
should make sure they are informed about these risks, even if they are very small or rare.  You should
always answer questions honestly.  Sometimes, patients may make it clear that they do not want to
have any information about the options, but want you to decide on their behalf.  In such
circumstances, you should do your best to ensure that the patient receives at least very basic
information about what is proposed.  Where information is refused, you should document this overleaf
or in the patient’s notes.
The law on consent
See the Department of Health’s Reference guide to consent for examination or treatment for a
comprehensive summary of the law on consent (also available at www.doh.gov.uk/consent).