Patient agreement to investigation or treatment
Patient’s surname/family name..…………………………………………………………...
Patient’s first names .…………………………………………………………………….….
Date of birth ………………………………………………………………………………….
NHS number (or other identifier)……………………………………………………….…..
 Male
 Female
Name of procedure/treatment:Excision of keratoacanthoma under local anaesthetic
Statement of health professional: (to be filled in by appropriate health professional.)
I have explained the procedure to the patient. In particular, I have explained:
Intended benefits: Removal of lesion, enable diagnosis and to aid relief of symptoms.
Serious or frequently occurring risks: Infection, pain, bleeding, persistent scar, nerve
injury, tendon injury, blood vessel injury, cyst recurrence, decreased range of motion, need
for further surgery.
I have also discussed any available alternative treatments (including no treatment) and
any particular concerns expressed by this patient.
The following leaflet has been provided ……………….…………………………………………
I consider the patient to be competent based upon his/her ability to believe, understand,
retain and weigh up the information provided to him/her and so reach a decision voluntarily
Signed:…….……………………………………
Date .. …………………….……….….
Name (PRINT) ………………………. ……….
Job title …….. ………………….…….
Statement of patient
I have read above and I agree to the procedure/course of treatment described on this form
Patient’s signature ……………………………
Date…………………………………...
Name (PRINT) ………………………………………………………………………………………
Confirmation of consent (to be completed by the health professional when the patient
attends for the procedure, if the patient has signed the form in advance)
Signed:…….……………………………………
Date .. …………………….…………..
Name (PRINT) ………………………. ……….
Job title …….. ………………….…….
Statement of interpreter (where appropriate)
I have interpreted the information above to the patient to the best of my ability and in a way
in which I believe s/he can understand.
Signed ………………………….………………
Date ………………..…………………
Name (PRINT) …………………..…………………………………………………………………..
www.primarycareforms.com