Iron infusion consent

Section A: Capacity and Decision-making - Does the patient have capacity? [□ Yes □ No] - If No, name of substitute decision-maker: [Substitute Decision-Maker Name] - Category of substitute decision-maker: [Category] Section B: Interpreter Requirement - Is an interpreter required? [□ Yes □ No] - If Yes, Name of interpreter: [Interpreter Name] - Interpreter code: [Code], Language: [Language] Section C: Procedure Request - Procedure(s) requested: [Specific Iron Infusion Type] Section D: Patient-Specific Risks - Doctor/clinician to document additional risks: [Additional Risks not in the information sheet] Section E: Risks of Not Having an Iron Infusion - Specific risks in not having an iron infusion: [Specific Risks] Section F: Alternative Treatment Options - Alternative treatment options: [Alternative Treatments] Section G: Doctor/Clinician Information - Doctor/clinician's explanation and opinion on understanding: [Explanation and Opinion] - Name of doctor/clinician: [Doctor/Clinician Name] - Designation: [Designation] - Signature: [Signature] - Date: [Date] Section H: Consent Acknowledgement of explanation (check all that apply): [ ] Iron infusion information sheet [ ] Medical condition and proposed treatment [ ] General and specific risks and benefits [ ] Prognosis and risks of non-treatment [ ] Alternative treatment options [ ] No guarantee of procedure success [ ] Treatment during life-threatening events [ ] Procedure may be performed by another clinician [ ] Consent for recording (if applicable) Consent given by: [Patient/Substitute Decision-Maker/Parent/Legal Guardian] Signature: [Signature] Date: [Date]