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Vascular Surgery in Tallaght University Hospital

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(Patient Name)___________________________ (MRN) ___________________________

I confirm that the proposed surgical procedure has been explained to me by (doctor) ___________________.

I have been given an opportunity to ask questions at this time. I have also been given a copy of this information leaflet to take away with me and read later.

signed _____________________________ date ______________________________

Medical Practitioner _____________________________ MCNo. ________________________

Printed: Wednesday 23 Jun, 2021