Jo R. Oneal

1926 Joanne Lane

Marquette, MI 49855

November 7, 2052

Dr. Rigoberto Stromain

Head Surgeon

Pinnacle Medical Center

1089 Pinewood Avenue

Marquette, MI 49855

To Whom It May Concern,

I, Jo R. Oneal, hereby waive my right to provide informed consent for the medical treatment or procedure as described below. I understand the nature of the treatment, the potential risks and benefits, and the alternatives, but I am choosing to waive my right to provide consent for the following reasons:

I am currently unconscious and unable to provide consent due to a severe car accident that occurred on November 5, 2052. My medical condition requires immediate surgery to address life-threatening injuries, and obtaining my consent is not feasible in this emergency situation.

I acknowledge that I have been informed about the nature of the treatment, its potential risks and benefits, and any available alternatives. I am aware that, by waiving my right to informed consent, I am entrusting my healthcare provider to make decisions in my best interest. I understand that this decision is made voluntarily and is in compliance with the policies and regulations of Memorial Hospital.

I have been given the opportunity to ask questions and seek clarification on any aspects of the treatment or procedure. My signature below signifies my understanding and agreement to this waiver:

Patient's Signature: Jo R. Oneal
Date: November 7, 2052

Dr. Rigoberto Stromain, MD

Pinnacle Medical Center