Patient agreement to investigation or treatment

Patient's details (or pre-printed label)

Patient's surname/family name:

Patient's first names:

Date of birth:

Responsible health professional:

Job title:

NHS number (or other identifier):

Male ⎕ Female ⎕

Special requirements:

(e.g. other language/communication methods)

To be retained in patient's notes

Name of proposed procedure or course of treatment

Electroconvulsive therapy: Unilateral ⎕ Bilateral ⎕ Either ⎕

(Please tick laterality)

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. In particular, I have explained:

⎕ The intended benefits and the use of bilateral or unilateral treatment

⎕ Serious or frequently occurring risks

⎕ What the procedure involves, the benefits and likely risks of any alternative treatments (including no treatment) and discussed any particular concerns of this patient

⎕ Which medication to take and not to take on the morning of ECT

I have also explained any procedures which may become necessary during the procedure