Request for signatory for planned medical investigation or surgery

(To be completed by social worker requesting service manager signature)

Name of child:	Date of birth:

Legal status:

Person(s) with parental responsibility:

Diagnosis:	Procedure/Investigation planned:

Consultant contact details	Date planned procedure/investigation

Name:

Telephone:

Address:

Answer the following

• What are the benefits and the risks of the proposed treatment as explained to you in clinic?

• What will the treatment involve?

• What if any are the implications of not having the treatment?

• What alternatives to procedure may be available?

• What the practical effects on their lives of having, or not having, the

treatment will be. (e.g. time in hospital, recovery time, follow up appointments)

Name of social worker:

Contact details:

Date:

On completion send to: Service Manager

4th Floor Northgate House

Section for completion by Service Manager

Answer the following:

Have you contacted the Consultant to discuss the medical questions above?

Are you satisfied that this procedure needs to take place and there are no viable alternatives?

Have you contacted the Designated Doctor for LAC for a further consultation?

Are you giving consent in your position as Senior Manager for Looked After Children?

Are you available to attend on the day of surgery to sign the written consent documentation?

If not, who have you delegated your responsibility to for this written consent?

(Authority to sign hospital consent form can only be delegated to an officer of Calderdale Children & Young Peoples Care Services)

Has this been agreed by the medical team performing the procedure?

Signature of Service Manager for Looked After Children

Name:

Signature:

Date:

(NB: PLEASE NOW SEND BACK TO DELEGATED AUTHORITY TO PROVIDE CONFIRMATION ON DAY OF SURGERY AND ENTER THIS CONSENT AGREEMENT INTO CASS AS EVIDENCE OF FORMAL CONSENT BY THE RIGHT AUTHORITY)