Full Name *		Sex	Male Female Other
DOB *		Age *
Phone *		Email *
Address
GP Surgery		Consent to share info with GP if required	Yes No

Clinician has checked correct details/ID for client*	Yes No
Consent to storage of health information	Yes No

*Good practice to check that contact details are correct and current.

Client is able to consent *	Yes No
Client is accompanied by someone able to consent on their behalf*	Yes No N/A

*(Mother, father or other adult with parental responsibility, legal guardian or person with lasting power of attorney).

Details of person consenting on behalf of another
Name		Relationship / legal status
Address

The client is happy to go ahead with the consultation and treatment. The clinician will explain the recommended treatment, including relevant benefits, potential side effects, and appropriate measures for managing any adverse reactions. *

Yes No

Signed	Sign here Clear	Date