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<div class="cp_whiteBox">
<p>This colonoscopy consent form has useful information about your procedure, so its important that you watch the videos and take your time to read and understand the information included in this care plan. </p>
<p>Please watch these videos before completing this consent form.</p>
<div class="embed-responsive embed-responsive-16by9" style="margin-top:15px; margin-bottom:15px;">
<iframe class="embed-responsive-item" src="https://www.drfalk.co.uk/wp-content/uploads/2018/10/C1.-Having-a-Colonoscopy.mp4?cl" allowfullscreen="true"></iframe>
</div>
<div class="embed-responsive embed-responsive-16by9" style="margin-top:15px; margin-bottom:15px;">
<iframe class="embed-responsive-item" src="https://www.drfalk.co.uk/wp-content/uploads/2018/10/C4.-What-happens-after-your-Colonoscopy.mp4?cl" allowfullscreen="true"></iframe>
</div>
<div class="embed-responsive embed-responsive-16by9" style="margin-top:15px; margin-bottom:15px;">
<iframe class="embed-responsive-item" src="https://www.drfalk.co.uk/wp-content/uploads/2018/10/C3.-How-to-prepare-for-a-Colonoscopy.mp4?cl" allowfullscreen="true"></iframe>
</div>
<div class="embed-responsive embed-responsive-16by9" style="margin-top:15px; margin-bottom:15px;">
<iframe class="embed-responsive-item" src="https://www.drfalk.co.uk/wp-content/uploads/2018/10/C2.-Colonoscopy-Reasons-Risks.mp4?cl" allowfullscreen="true"></iframe>
</div>
<div class="embed-responsive embed-responsive-16by9" style="margin-top:15px; margin-bottom:15px;">
<iframe class="embed-responsive-item" src="https://www.drfalk.co.uk/wp-content/uploads/2018/10/C5.-Alternatives-to-having-a-Colonoscopy.mp4?cl" allowfullscreen="true"></iframe>
</div>
</div>
<div class="cp_whiteBox">
<h2>Patient agreement of investigation or treatment</h2>
<div class="cp_question">
<div class="row">
<div class="col-sm-12">
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_requirements" id="cp_requirements" value="Special requirements eg other language/ other communication method"> Special requirements eg other language/ other communication method</input>
</div>
</div>
</div>
</div>
<div class="cp_question">
<div class="row">
<div class="col-sm-12">
<div>
<div class="form-check">
<input class="form-check-input" type="radio" name="cp_gender" id="cp_genderMale" value="Male"> Male</input>
</div>
<div class="form-check">
<input class="form-check-input" type="radio" name="cp_gender" id="cp_genderFemale" value="Female"> Female</input>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="cp_whiteBox">
<h2>Name of proposed procedure or course of treatment</h2>
<p>(include brief explanation if medical term not clear)</p>
<div class="cp_question">
<div class="row" style="margin-top: 15px;">
<div class="col-sm-6">
<label class="cp_label" for="cp_colonoscopy">Colonoscopy:</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<div>
<div class="form-check">
<input class="form-check-input" type="radio" name="cp_colonoscopy" id="cp_colonoscopyBiopsy" value="+/- Biopsy "> +/- Biopsy </input>
</div>
<div class="form-check">
<input class="form-check-input" type="radio" name="cp_colonoscopy" id="cp_colonoscopyPolypectomy" value="+/- Polypectomy "> +/- Polypectomy </input>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="cp_whiteBox">
<h2>Statement of health professional</h2>
<p>(to be filled in by health professional with appropriate knowledge of proposed procedure, as specified in consent policy)</p>
<p>I have explained the procedure to the patient. In particular, I have explained:</p>
<div class="cp_question">
<div class="row" style="margin-top: 15px;">
<div class="col-sm-6">
<label class="cp_label" for="cp_benefits">The intended benefits</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_benefits_1" id="cp_benefits_1" value="To assess large bowel"> To assess large bowel</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_benefits_2" id="cp_benefits_2" value="Surveillance"> Surveillance</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_benefits_3" id="cp_benefits_3" value="To review findings of any previous endoscopy"> To review findings of any previous endoscopy</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_benefits_4" id="cp_benefits_4" value="To visualise and investigate the large bowel within the remit of the Bowel Cancer Screening programme following a positive/abnormal faecal occult test kit(s) to exclude abnormal pathology. "> To visualise and investigate the large bowel within the remit of the Bowel Cancer Screening programme following a positive/abnormal faecal occult test kit(s) to exclude abnormal pathology. </input>
</div>
</div>
</div>
</div>
<div class="cp_question">
<div class="row" style="margin-top: 15px;">
<div class="col-sm-6">
<label class="cp_label" for="cp_risks">Serious or frequently occurring risks</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_1" id="cp_risks_1" value="Bleeding 1:100 (diagnostic)"> Bleeding 1:100 (diagnostic)</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_2" id="cp_risks_2" value="1:50 (Therapeutic)"> 1:50 (Therapeutic)</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_3" id="cp_risks_3" value="Perforation 1:1000 (diagnostic)"> Perforation 1:1000 (diagnostic)</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_4" id="cp_risks_4" value="1:500 (Therapeutic)"> 1:500 (Therapeutic)</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_5" id="cp_risks_5" value="Sedation risk (slowed breathing)"> Sedation risk (slowed breathing)</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_6" id="cp_risks_6" value="Missed pathology"> Missed pathology</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_7" id="cp_risks_7" value="Other risks"> Other risks</input>
</div>
</div>
</div>
</div>
<div class="cp_question">
<div class="row" style="margin-top: 15px;">
<div class="col-sm-6">
<label class="cp_label" for="cp_extraProcedures">Any extra procedures which may become necessary during the procedure </label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_extraProcedures_1" id="cp_extraProcedures_1" value="+/- Blood Transfusion in the event of haemorrhage "> +/- Blood Transfusion in the event of haemorrhage </input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_extraProcedures_2" id="cp_extraProcedures_2" value="+/- Surgery in the event of perforation "> +/- Surgery in the event of perforation </input>
</div>
<p>OTHERS:</p>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_extraProcedures_3" id="cp_extraProcedures_3" value="+/- Tattoo"> +/- Tattoo</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_extraProcedures_4" id="cp_extraProcedures_4" value="+/- Dye spray"> +/- Dye spray</input>
</div>
<div class="row" style="margin-top: 15px;">
<div class="col-sm-12">
<label class="cp_label" for="cp_extraProceduresSpecify">(Specify):</label>
<input type="text" name="cp_extraProceduresSpecify" id="cp_extraProceduresSpecify" class="form-control" style="width: 100%;"></input>
</div>
</div>
</div>
</div>
</div>
<div class="cp_question">
<div class="row" style="margin-top: 15px;">
<div class="col-sm-12">
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_extraProcedures_5" id="cp_extraProcedures_5" value="I have also discussed what the procedure is likely to involve, the benefits and risks of any available alternative treatments (including no treatment) and any particular concerns of this patient.">I have also discussed what the procedure is likely to involve, the benefits and risks of any available alternative treatments (including no treatment) and any particular concerns of this patient. </input>
</div>
</div>
</div>
</div>
<div class="cp_question">
<div class="row" style="margin-top: 15px;">
<div class="col-sm-12">
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_extraProcedures_6" id="cp_extraProcedures_6" value="Tissue samples will be retained by the hospital according to NWLH NHS Trust Policy ">Tissue samples will be retained by the hospital according to NWLH NHS Trust Policy </input>
</div>
</div>
</div>
</div>
<div class="cp_question">
<div class="row" style="margin-top: 15px;">
<div class="col-sm-12">
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_extraProcedures_7" id="cp_extraProcedures_7" value="The following leaflet/tape has been provided."> The following leaflet/tape has been provided.</input>
</div>
</div>
</div>
</div>
<div class="cp_question">
<div class="row" style="margin-top: 15px;">
<div class="col-sm-6">
<label class="cp_label" for="cp_procedureInvolves">This procedure will involve: </label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_procedureInvolves_1" id="cp_procedureInvolves_1" value="general and/or regional anaesthesia"> general and/or regional anaesthesia</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_procedureInvolves_2" id="cp_procedureInvolves_2" value="local anaesthesia sedation "> local anaesthesia sedation </input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_procedureInvolves_3" id="cp_procedureInvolves_3" value="Entonox"> Entonox</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_procedureInvolves_4" id="cp_procedureInvolves_4" value="sedation "> sedation </input>
</div>
</div>
</div>
</div>
<div class="row" style="margin-top: 15px;">
<div class="col-sm-6">
<label class="cp_label" for="cp_signed">Signed</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="text" name="cp_signed" id="cp_signed" class="form-control" style="width: 100%;"></input>
</div>
</div>
<div class="row" style="margin-top: 15px;">
<div class="col-sm-6">
<label class="cp_label" for="cp_date">Date</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="date" name="cp_date" id="cp_date" class="form-control" placeholder="dd/mm/yyyy"></input>
</div>
</div>
<div class="row" style="margin-top: 15px;">
<div class="col-sm-6">
<label class="cp_label" for="cp_sigName">Name</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="text" name="cp_sigName" id="cp_sigName" class="form-control" style="width: 100%;"></input>
</div>
</div>
<div class="row" style="margin-top: 15px;">
<div class="col-sm-6">
<label class="cp_label" for="cp_jobTitle">Job title</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="text" name="cp_jobTitle" id="cp_jobTitle" class="form-control" style="width: 100%;"></input>
</div>
</div>
</div>
<div class="cp_whiteBox">
<h2>Contact details</h2>
<div class="row" style="margin-top: 15px;">
<div class="col-sm-12">
<label class="cp_label" for="cp_contactDetails">(if patient wishes to discuss options later)</label>
<textarea class="form-control" name="cp_contactDetails" id="cp_contactDetails" rows="3" style="width: 100%;"></textarea>
</div>
</div>
</div>
<div class="cp_whiteBox">
<h2>Statement of interpreter</h2>
<p>(where appropriate)</p>
<p>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.</p>
<div class="row" style="margin-top: 15px;">
<div class="col-sm-6">
<label class="cp_label" for="cp_signed">Signed</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="text" name="cp_signedInterpreter" id="cp_signedInterpreter" class="form-control" style="width: 100%;"></input>
</div>
</div>
<div class="row" style="margin-top: 15px;">
<div class="col-sm-6">
<label class="cp_label" for="cp_dateInterpreter">Date</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="date" name="cp_dateInterpreter" id="cp_dateInterpreter" class="form-control" placeholder="dd/mm/yyyy"></input>
</div>
</div>
<div class="row" style="margin-top: 15px;">
<div class="col-sm-6">
<label class="cp_label" for="cp_sigNameInterpreter">Name</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="text" name="cp_sigNameInterpreter" id="cp_sigNameInterpreter" class="form-control" style="width: 100%;"></input>
</div>
</div>
</div>
<div class="cp_whiteBox">
<h2>Statement of patient Patient</h2>
<p>Please read this form carefully. If your treatment has been planned in advance, you should already have your own copy, which describes the benefits and risks of the proposed treatment. If not, you will be offered a copy now. If you have any further questions, do ask - we are here to help you. You have the right to change your mind at any time, including after you have signed this form.</p>
<p><b>I agree</b> to the procedure or course of treatment described on this form.</p>
<p><b>I understand</b> that you cannot give me a guarantee that a particular person will perform the procedure. The person will, however, have appropriate experience.</p>
<p><b>I understand</b> that I will have the opportunity to discuss the details of anaesthesia with an anaesthetist before the procedure, unless the urgency of my situation prevents this. (This only applies to patients having general or regional anaesthesia.)</p>
<p><b>I understand</b> that any procedure in addition to those described on this form will only be carried out if it is necessary to save my life or to prevent serious harm to my health.</p>
<p><b>I have been told</b> about additional procedures which may become necessary during my treatment. I have listed below any procedures <b>which I do not wish to be carried out</b> without further discussion.</p>
<div class="row" style="margin-top: 15px;">
<div class="col-sm-12">
<textarea class="form-control" name="cp_told" id="cp_told" rows="3" style="width: 100%;"></textarea>
</div>
</div>
<p>I agree to the use of any tissue which is being removed during this operation being used for research and/or teaching if needed?</p>
<div class="row" style="margin-top: 15px;">
<div class="col-sm-6">
<label class="cp_label" for="cp_patientSignature">Patient's signature</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="text" name="cp_patientSignature" id="cp_patientSignature" class="form-control" style="width: 100%;"></input>
</div>
</div>
<div class="row" style="margin-top: 15px;">
<div class="col-sm-6">
<label class="cp_label" for="cp_patientDate">Date</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="date" name="cp_patientDate" id="cp_patientDate" class="form-control" placeholder="dd/mm/yyyy"></input>
</div>
</div>
<div class="row" style="margin-top: 15px;">
<div class="col-sm-6">
<label class="cp_label" for="cp_patientName">Name</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="text" name="cp_patientName" id="cp_patientName" class="form-control" style="width: 100%;"></input>
</div>
</div>
<p><b>A witness should sign below if the patient is unable to sign but has indicated his or her consent. Young people/children may also like a parent to sign here (see notes).</b></p>
<div class="row" style="margin-top: 15px;">
<div class="col-sm-6">
<label class="cp_label" for="cp_signedWitness">Signed</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="text" name="cp_signedWitness" id="cp_signedWitness" class="form-control" style="width: 100%;"></input>
</div>
</div>
<div class="row" style="margin-top: 15px;">
<div class="col-sm-6">
<label class="cp_label" for="cp_date">Date</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="date" name="cp_dateWitness" id="cp_dateWitness" class="form-control" placeholder="dd/mm/yyyy"></input>
</div>
</div>
</div>
<div class="cp_whiteBox">
<h2>Confirmation of consent</h2>
<p>(to be completed by a health professional when the patient is admitted for the procedure, if the patient has signed the form in advance)</p>
<p>On behalf of the team treating the patient, I have confirmed with the patient that s/he has no further questions and wishes the procedure to go ahead.</p>
<div class="row" style="margin-top: 15px;">
<div class="col-sm-6">
<label class="cp_label" for="cp_signedConsent">Signed</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="text" name="cp_signedConsent" id="cp_signedConsent" class="form-control" style="width: 100%;"></input>
</div>
</div>
<div class="row" style="margin-top: 15px;">
<div class="col-sm-6">
<label class="cp_label" for="cp_dateConsent">Date</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="date" name="cp_dateConsent" id="cp_dateConsent" class="form-control" placeholder="dd/mm/yyyy"></input>
</div>
</div>
<div class="row" style="margin-top: 15px;">
<div class="col-sm-6">
<label class="cp_label" for="cp_sigNameConsent">Name</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="text" name="cp_sigNameConsent" id="cp_sigNameConsent" class="form-control" style="width: 100%;"></input>
</div>
</div>
<div class="row" style="margin-top: 15px;">
<div class="col-sm-6">
<label class="cp_label" for="cp_jobTitleConsent">Job title</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="text" name="cp_jobTitleConsent" id="cp_jobTitleConsent" class="form-control" style="width: 100%;"></input>
</div>
</div>
<div class="cp_question">
<div class="row" style="margin-top: 15px;">
<div class="col-sm-12">
<label class="cp_label" for="cp_importantNotes">Important notes: (tick if applicable)</label>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_importantNotes_1" id="cp_importantNotes_1" value="See also advance directive/living will (e.g. Jehovah's Witness form)"> See also advance directive/living will (e.g. Jehovah's Witness form)</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_importantNotes_2" id="cp_importantNotes_2" value="Patient has withdrawn consent (ask patient to sign/date here)"> Patient has withdrawn consent (ask patient to sign/date here)</input>
</div>
<input type="text" name="cp_withdrawnSig" id="cp_withdrawnSig" class="form-control" style="width: 100%;"></input>
<input type="date" name="cp_withdrawnDate" id="cp_withdrawnDate" class="form-control" placeholder="dd/mm/yyyy"></input>
</div>
</div>
</div>
</div>
<div class="cp_whiteBox">
<h2>Guidance for health professionals</h2>
<p>(to be read in conjunction with consent policy)</p>
<h3>What a consent form is for</h3>
<p>This form documents the patient's agreement to go ahead with the investigation or treatment you have proposed. It is not a legal waiver - if patients, for example, do not receive enough information on which to base their decision, then the consent may not be valid, even though the form has been signed. Patients are also entitled to change their mind after signing the form, if they retain capacity to do so. The form should act as an aide-memoire to health professionals and patients, by providing a check-list of the kind of information patients should be offered, and by enabling the patient to have a written record of the main points discussed. In no way, however, should the written information provided for the patient be regarded as a substitute for face-to face discussions with the patient.</p>
<h3>The law on consent</h3>
<p>See the Department of Health's Reference guide to consent for examination or treatment for a comprehensive summary of the law on consent (also available at <a href="www.doh.gov.uk/consent" target="_blank" rel="noopener noreferrer">www.doh.gov.uk/consent</a>).</p>
<h3>Who can give consent </h3>
<p>Everyone aged 16 or more is presumed to be competent to give consent for themselves, unless the opposite is demonstrated. If a child under the age of 16 has "sufficient understanding and intelligence to enable him or her to understand fully what is proposed", then he or she will be competent to give consent for himself or herself. Young people aged 16 and 17, and legally 'competent' younger children, may therefore sign this form for themselves, but may like a parent to counter sign as well. If the child is not able to give consent for himself or herself, some-one with parental responsibility may do so on their behalf and a separate form is available for this purpose. Even where a child is able to give consent for himself or herself, you should always involve those with parental responsibility in the child's care, unless the child specifically asks you not to do so. If a patient is mentally competent to give consent but is physically unable to sign a form, you should complete this form as usual, and ask an independent witness to confirm that the patient has given consent orally or non-verbally.</p>
<h3>When NOT to use this form</h3>
<p>If the patient is 18 or over and is not legally competent to give consent, you should use form 4 (form for adults who are unable to consent to investigation or treatment) instead of this form. A patient will not be legally competent to give consent if:</p>
<ul>
<li style="list-style:inherit; margin-left: 15px;">they are unable to comprehend and retain information material to the decision and/or </li>
<li style="list-style:inherit; margin-left: 15px;">they are unable to weigh and use this information in coming to a decision. </li>
</ul>
<p>You should always take all reasonable steps (for example involving more specialist colleagues) to support a patient in making their own decision, before concluding that they are unable to do so. Relatives cannot be asked to sign this form on behalf of an adult who is not legally competent to consent for himself or herself. </p>
<h3>Information </h3>
<p>Information about what the treatment will involve, its benefits and risks (including side-effects and complications) and the alternatives to the particular procedure proposed, is crucial for patients when making up their minds. The courts have stated that patients should be told about 'significant risks which would affect the judgement of a reasonable patient. 'Significant' has not been legally defined, but the GMC requires doctors to tell patients about 'serious or frequently occurring risks. In addition, if patients make clear they have particular concerns about certain kinds of risk, you should make sure they are informed about these risks, even if they are very small or rare. You should always answer questions honestly. Sometimes, patients may make it clear that they do not want to have any information about the options, but want you to decide on their behalf. In such circumstances, you should do your best to ensure that the patient receives at least very basic information about what is proposed. Where information is refused, you should document this on the reverse of this page of the form or in the patient's notes.</p>
<p>To find out more about Crohn's Disease we have added this <a href="https://www.drfalk.co.uk/wp-content/uploads/2020/10/Dr-Falk_Crohns-Disease-Explained.pdf?cl" target="_blank" rel="noopener noreferrer">Crohns-Disease-Explainer PDF document</a> for you to read, it explains what Crohn's is and how it affects your body. </p>
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