ࡱ> 352 bjbj 8 ee   dddddxxx8,xhh$f d dd"CCCFddCCCC`:C80hC K CC dW|C  Sh   *: Please READ CAREFULLY and complete the following form, which gives your permission to have upper GI physiology investigations performed: You have been referred for upper GI physiology studies at xxxxx Hospital, by the consultant or your GP who you contacted regarding your GI symptoms. You will have your studies carried out by a member of staff from the GI physiology team, on occasions a doctor or student may also be in attendance (to observe and learn about the procedure); if you would prefer not to have others present, please state below. The diagnostic tests will assess your oesophageal function by utilising High Resolution Oesophageal Manometry and measure the extent of your acidic reflux by means of a 24hr pH (+/-) Impedance monitoring study. You are free to ask any questions (before, during or after the investigation), and may withdraw your consent at any time during the procedure(s). I am / I am not* (*delete as appropriate) willing for other people to be present (doctor or student from outside the department). I am / I am not* (*delete as appropriate) willing for the data from my investigations to be used for teaching and/or research purposes (anonymously, you will not be identified) I have / I have not* (*delete as appropriate) read and fully understood the High Resolution Oesophageal Manometry and pH Monitoring booklet (Date of booklet). I am / I am not* (*delete as appropriate) willing to have my test results and reports readily accessible and distributed to the referring consultant (or his/her secretary). FULL NAME: DATE OF BIRTH: SIGNED: DATE: To be completed by staff member prior to procedure(s): I have explained the procedure to the patient and have addressed any particular concerns of this patient Signed: Date: Name (PRINT): Job title: Statement of interpreter (where appropriate): I have interpreted the information above to the patient to the best of my ability and in a way in which I believe s/he can understand Signed: Date: Name (PRINT):     o}  I v  ! 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[[oo{{!"(3bEX\{|  47P_`ab3FF [[oo{{!"(3bEX\{|  47P_`ab3FFJW\N9i OKV &,7Iz7}8Q; ==mSexcRf\p8|H{r"_ Z=i@2222@UnknownG*Ax Times New Roman5Symbol3. *Cx Arial7.@Calibri7@CambriaA$BCambria Math"qhG3GG3G200!r4KQHX  ?exc2!xx Please READ CAREFULLY and complete the following form, which gives your permission to have upper GI physiology studies performed:Warren JacksonJackson, WarrenOh+'0,< T`    Please READ CAREFULLY and complete the following form, which gives your permission to have upper GI physiology studies performed:Warren JacksonNormalJackson, Warren2Microsoft Office Word@@K?L@`@`0՜.+,0| hp  ^Castle Hill Hospital Please READ CAREFULLY and complete the following form, which gives your permission to have upper GI physiology studies performed: Title  !#$%&'()+,-./014Root Entry F`61Table WordDocument8 SummaryInformation("DocumentSummaryInformation8*CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q