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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
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