Consent Form

INFORMED CONSENT FORM FOR CANNABIS THERAPY 

76 Harley Street, London W1G 7HH e: info@lvlhealth.co.uk t: + 44 (0)333 366 1033 

Principle Clinician (Pain Specialist): 

Clinical Service Operator: 

Clinic Address: 

Doctor Statement 

I confirm I am a healthcare professional with an appropriate knowledge of the proposed treatment, as specified in the Consent Policy. I have verbally explained the treatment in detail and accompanying written information is to be shared with the patient.  

I have discussed:  

1. 1. The intended benefits of the treatment, which are to relieve chronic pain and improve quality of life. 
   2. The possible risks involved 
      (all precautions are taken to ensure any risks are minimised, however all procedures carry some risk and I have set out below any significant, unavoidable, or frequently occurring risks.) 
      Possible side effects of the treatment can include: Difficulty concentrating, Drowsiness and lethargy, Loss of balance, Memory loss, Gastrointestinal effects such as nausea or diarrhoea, Dry mouth, Anxiety (reported in THC only formulations), Psychosis (reported in THC only formulations) 
   3. what the treatment is likely to involve, the benefits and risks of alternative treatment (including no treatment) and any concerns expressed by the patient.  

Signed: 

Date:  

(Health Care professional) 
 Name: 
GMC Number: 
   

Contact information 

If you have any questions or concerns during your treatment or following it, please contact us: 

Email: info@lvlhealth.co.uk 

Telephone: +44 (0)333 366 1033 

Consent of patient 

Please read the following statements about your consent to take part in this clinical service. to take part, you must confirm your consent for all points (1-12 inclusive) 

1. 1. 1. After contacting LVL Health and reviewing information around the clinical service offering in relation to the unlicensed medical cannabis treatment on offer I consent to attend this clinic to access the medical cannabis treatment on offer and the clinical oversight provided by the clinic’s Specialist doctors. 
      2. I confirm that I have signed previously another informed consent form entitled Diagnostic Consent Form, in which I agreed to provide a urine sample for a cannabis screening test and a urine sample for a pregnancy test (if appropriate) and a saliva sample for a genetic test, and to have my data collected for clinical oversight and for service evaluation purposes during my treatment at the clinic. 
      3. I understand that being a patient is voluntary, and that I am free to leave at any time without giving a reason, and without my medical care or legal rights being affected. 
      4. I understand that medical cannabis has side effects and can limit my ability to drive a car or operate machinery and that I must adhere to the DVLA advice as described in the Patient Information Sheet. 
      5. I understand that relevant sections of my medical notes and data collected may be looked at by individuals from the clinic, from LVL Health, independent auditors, its representatives, consultants, contractors, regulatory authorities where it is relevant to me being a patient at the clinic. By signing this consent form, I give permission for these parties to access my medical records held at LVL Health. 
      6. I understand that data protection laws differ in non-UK countries and if I do not want my anonymised data to be sent outside of the UK, I will not be able to become a patient of the clinic. I agree that my samples and anonymised data can be sent outside of the UK. 
      7. I assign all rights related data and materials I provide to the clinic and LVL Health, and acknowledge that LVL Health will own such materials and the rights to them. 
      8. I confirm that the risks, benefits, and alternatives of this treatment have been discussed with me and my questions have been answered to my satisfaction and understanding. 
      9. I understand that for the duration of this treatment it is my responsibility to ensure that the results of blood tests and other investigations are transmitted to LVL Heath in a timely fashion. 
      10. I confirm that I am willing to receive unencrypted emails/texts/phone calls related to my treatment. 
      11. I understand that written correspondence following appointments with a doctor will be sent to me via email and/or uploaded to a Patient Portal. I understand that the clinic and LVL Health recommend that these clinic letters and notes are shared with my GP. 
      12. I have read and understood the Patient Information Sheet, the above information, and the Privacy Policy. I agree to this treatment and the use of my data in accordance with the Privacy Policy