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Heartburn Health Check Procedure Consent Form

Heartburn Health Check procedure

Consent form V3 July 2026

Please complete this form if you would like to volunteer for the Heartburn Health Check procedure.

The testing is designed to facilitate the training of new practitioners by conducting the capsule sponge test in the presence of an accredited trainer.

By agreeing to take part as a volunteer in the procedure, I understand that:

- I am under no obligation to volunteer

- I can change my mind at any point

- My real personal data (name, address, date of birth) will not be used or retained.

- I will have the capsule sponge test administered by either a nurse or Dr working at Finchley Memorial Hospital CDC

Confirmation of choice I have read the statements above and have had any questions answered:

Yes

I agree to volunteer in the test procedure

Yes

Consent observed by:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

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July 21, 2026 11:27 am BST

Heartburn Health Check Procedure Consent Form Uploaded by Tap Tarika - [email protected] IP 212.42.190.49

July 21, 2026 11:29 am BST

TPIR Inbox - [email protected] added by Tap Tarika - [email protected] as a CC'd Recipient Ip: 212.42.190.49