Procedure Consent Form
Please fill out the form with your information below.
Consent for Treatment
I acknowledge that the nature, benefits, and potential risks of the procedure have been explained to me. I have had the opportunity to ask questions and receive satisfactory answers. I understand that unforeseen complications may arise, and additional procedures may be necessary. I authorize the medical provider and their team to perform the procedure.
Release of Liability
I acknowledge that medical procedures carry some risks, including but not limited to infection, bleeding, scarring, and other unforeseen complications. I release the clinic and its medical staff from any liability related to the procedure, except in cases of negligence.
Authorization & Signature
I certify that I have read and understand this consent form. I voluntarily agree to proceed with the procedure.
Name:
Date:
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