INFORMED PATIENT CONSENT

1 Patient Data

2 Patient's Legal Representative

* Used for minors and adults lacking legal capacity (pursuant to Art. 8(3)-(5) of the methodological norms).

3 Medical Procedure (description)

4 Information Provided to Patient

The following information regarding the medical procedure has been provided to the patient:

Data on health status / Diagnosis / Prognosis
Nature and purpose of the proposed medical procedure
Proposed medical interventions and/or recommended therapeutic strategy
Potential benefits and consequences of the proposed medical procedures
Potential risks of each proposed alternative
Viable treatment alternatives
Potential risks of not performing the proposed medical procedure and/or not following medical recommendations

5 Consent for Sample Collection

The patient consents to the collection, storage and use of biological samples

6 Other Information Provided to Patient

  • Information about available medical services
  • Information about the identity and professional status of the treating staff*
  • Information about the rules/practices of the medical facility that must be observed
  • The patient has been informed of the right to a second medical opinion

7 Continued Information

The patient wishes to continue being informed about their health status

Consent / Refusal

Patient's Signature / Legal Representative's Signature

Sign with your finger

Medical Staff Table

No. Full name Professional status
1
2
3

Fill in all required fields, select Yes/No, choose Consent or Refusal, and sign.

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