Iron infusion consent

Section A: Capacity and Decision-making - Does the patient have capacity? [Yes] Section B: Interpreter Requirement - Is an interpreter required? [No] Section C: Procedure Request - Procedure(s) requested: [Ferric Carboxymaltose Infusion] Section D: Patient-Specific Risks - Doctor/clinician to document additional risks: [Potential for allergic reaction, transient hypotension] Section E: Risks of Not Having an Iron Infusion - Specific risks in not having an iron infusion: [Continued fatigue, worsening anaemia, decreased quality of life] Section F: Alternative Treatment Options - Alternative treatment options: [Oral iron supplements, dietary modifications] Section G: Doctor/Clinician Information - Doctor/clinician's explanation and opinion on understanding: [The patient understands the procedure, risks, and alternatives and agrees to proceed.] - Name of doctor/clinician: [Dr. Thomas Kelly] - Designation: [General Practitioner] - Signature: [Dr. Thomas Kelly] - Date: [1 November 2024] Section H: Consent Acknowledgement of explanation (check all that apply): [X] Iron infusion information sheet [X] Medical condition and proposed treatment [X] General and specific risks and benefits [X] Prognosis and risks of non-treatment [X] Alternative treatment options [X] No guarantee of procedure success [X] Treatment during life-threatening events [X] Procedure may be performed by another clinician Consent given by: [Patient] Signature: [John Doe] Date: [1 November 2024]