Minor Operations Consent Form

Patient Name:

Address:

Name of procedure (include brief explanation if medical term not clear)

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Statement of Health Professional (to be filled in by health professional with appropriate
knowledge of proposed procedure, as specified in consent policy)

I have explained the procedure to the patient/parent. In particular, I have explained:

1. The intended benefits:

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2. Serious or frequently occurring risks, including infection, reoccurrence, scarring and

bleeding:

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I have also discussed what the procedure is likely to involve, the benefits and the risks of any
available alternative treatment (including no treatment) and any particular concerns of those
involved.

Signed: ……………………………………………….……. Date: ………………………….…...….

Name: (PRINT)………………………………….………….. Job Title: ………………………………

Statement of Patient

I agree to the procedure described above.

I understand that the procedure will involve local anaesthesia.

Signed: ……………………………………………….……. Date: ………………………………..….

Name: (PRINT)………………………………….…………..

Suffolk GP Federation CIC, Riverside Clinic, 2 Landseer Road, Ipswich, IP3 0AZ