General Practitioner's Details
Next of Kin Details
Do you have any know allergies?
I consent to my case being discussed in Multidisciplinary Meetings as deemed appropriate by Dr Host:
Video and still images are occasionally taken during operative procedures. These become a part of your confidential medical records. We also would like to ask you for permission to use these photos for educational purposes in addition to their use as part of your medical care. All images used for purposes other than the medical records are de-identified. Names are not used and as far as possible identifying factors are masked.
Do you consent to these images being used for the purpose of (1) teaching, (2) publication in medical journals, (3) educating patients?
This field is for validation purposes and should be left unchanged.