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Address:
Date of birth:
Facility:
Sex:
Heart Attack
Yes
No
Yes
No
Yes
No
Yes
No
rare.
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SW9152
v5.00 - 02/2011
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Given name(s):
Address:
Date of birth:
Sex:
F. Patient consent
No
Name of Substitute
Decision Maker/s: ...............................................................................................................
G. Doctor/delegate statement
I have explained to the patient all the above points
under the Patient Consent section (G) and I am of
the opinion that the patient/substitute decisionmaker has understood the information.
Signature: .....................................................................................................................................
Name of
Doctor/delegate: ..........................................................................................................................
Designation:.....................................................................................................................................
Signature: ..........................................................................................................................................
Date: .......................................................................................................................................................
H. Interpreters statement
I have given a sight translation in
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