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: ________________________________________________
Published on May 9, 2012
www.sportsmedinfo.co.za The entire procedure will be explained to the patient b...