Bronchoscope Consent Form Updated
Bronchoscope Consent Form Updated
Allergy MBChB cum laude (US), DCH (SA), FCPaed (SA), MMed
cum laude (US), Cert Pulmonology (SA) Paed
MBChB (UCT), DCH (SA), DA (SA), FCPaed (SA),
MMed cum laude (US), Cert Pulmonology (SA) Paed
PATIENT DETAIL
Surname:
Forename:
Date of birth:
PROPOSED TREATMENT
is proposed.
T: 021 003 7272 | F: 086 548 3713 | AH: 021 712 6699 | [email protected] | www.chestandallergy.co.za
Suite 1610, Christiaan Barnard Memorial Hospital, 25 D.F. Malan Street, Cape Town City Centre, 8000 | PO Box 914, Cape Town, 8000
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Chest & Dr Fiona E Kritzinger Dr Taryn Gray
Allergy MBChB cum laude (US), DCH (SA), FCPaed (SA), MMed
cum laude (US), Cert Pulmonology (SA) Paed
MBChB (UCT), DCH (SA), DA (SA), FCPaed (SA),
MMed cum laude (US), Cert Pulmonology (SA) Paed
4. Individual Risks
I understand the following are possible significant risks and complications specific to my child’s individual circumstances, that I
have considered these in deciding my child will have the procedure.
DECLARATION BY DOCTOR
I declare that I have explained to the parent(s) / guardian the nature of the patient’s condition, the procedure to be performed, and
discussed the risks that particularly concern the patient. I have given the parent(s) / guardian an opportunity to ask questions and I
have answered these.
Doctor’s name
Print name
INTERPRETER’S DECLARATION
I confirm I have accurately interpreted the contents of this form and the related conversations between the patient and the doctor.
Interpreter’s name
Print name
T: 021 003 7272 | F: 086 548 3713 | AH: 021 712 6699 | [email protected] | www.chestandallergy.co.za
Suite 1610, Christiaan Barnard Memorial Hospital, 25 D.F. Malan Street, Cape Town City Centre, 8000 | PO Box 914, Cape Town, 8000
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