Example carer and comforter support form
Published 18 January 2023
Applies to England
© Crown copyright 2023
This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-government-licence/version/3 or write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: psi@nationalarchives.gov.uk.
Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned.
This publication is available at https://www.gov.uk/government/publications/breast-screening-guidance-on-implementation-of-ionising-radiation-medical-exposure-regulations-2017/example-carer-and-comforter-support-form
This is an example of how carer and comforter consent form could be presented. The detail provided is not intended for direct adoption in the clinical environment. Clinical departments should adapt the template to reflect NHS BSP guidance and local practice.
Carer and comforter support form for women attending for breast screening services
The relative or friend you have attended with today has been invited for a breast screening mammogram appointment. Your support is necessary to allow the mammogram to be adequately achieved.
By agreeing to remain in the room to provide support during the mammographic examination, you will be exposed to a very small amount of radiation.
The mammographer will advise you on where to stand, and provide you with personal protective equipment as necessary to minimise your radiation exposure.
We do not permit individuals who are or may be pregnant to perform this supportive role. You must also be over 18 years old.
If you are willing to proceed, please read and complete the following section.
I understand that I will be exposed to a very small amount of radiation. I am willing to support my relative/friend during this mammographic examination.
Carer and comforter details
Operator details
I confirm I have provided the carer and comforter with information on the benefits and risks of performing this role. I have authorised this exposure under the authorisation guidelines issued by [name] IR(ME)R practitioner.
