Issuu on Google+

PATIENT  CONSENT  FORM:  Chronic  Exertional  Compartment  Pressure  Syndrome   Dr.  Gavin  Shang         PR:  0342335   Sports  Physician   MBBCH  (WITS)  MPHIL  SPORTS  MED  (UCT/SSISA)     The  entire  procedure  will  be  explained  to  the  patient  before  proceeding  and  this   document  of  understanding  and  consent  signed.   For  your  safety  and  protection,  and  for  our  information,  please  can  we  be  informed  of  any   of  the  following  prior  to  the  procedure.     Pregnancy,  bleeding  disorders,  allergies  and  malignancies:  _____________________________   _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _____________________________________________________________________________________     Please  list  any  medications  you  are  currently  taking:  ____________________________________   _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _____________________________________________________________________________________     Localized  tissue  trauma  or  acute  inflammation,  are  also  deemed  inappropriate  for  this   investigation.  This  will  be  assessed  prior  to  the  procedure.     Treatment  Consent:     I,  the  undersigned,  hereby  give  my  consent  to  Dr  Gavin  Shang  to  assess  and  treat  me,   having  provided  a  full  verbal  explanation  at  the  time  of  consultation.     I  understand  I  have  the  right  to  decline  any  and  all  procedures/treatment  offered  to  me  at   any  time.     I  understand  the  consultant  may  discuss  my  treatment  with  other  consultants  in  line  with   the  clinic’s  multidisciplinary  approach.     Signature:  ____________________________________________________________________________________   (Parent  or  Guardian  Signature  if  under  18  years  of  age)     Date:  ________________________________________________      

www.sportsmedinfo.co.za  


consent-form-compartment-pressure-testing