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This information leaflet is produced by the Vascular Surgery Unit, Tallaght Hospital, Dublin 24.
Phone: +353 (0)1 414 4017
Fax: +353 (0)1 414 2212



(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: Thursday 27th of June 2019 10:53:23 AM