Free Procedure Consent Form Template
Procedure Consent Form
Please fill out the form with your information below.
Name
Date of Birth
Contact Number
Emergency Contact Name
Emergency Contact Number
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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