Surgical Consent Form

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Surgical Consent Form

Patient Name:

Date of Birth:

Current Residence:

Address

City

State / Province

ZIP / Postal code

Procedure:

Surgeon Name:

Surgery Date:

I, , consent to the procedure described above. I understand the risks, benefits, and alternatives. I have had my questions answered. I acknowledge that no guarantees have been made regarding the outcome of the surgery. I authorize the medical team to perform any additional procedures they deem necessary during the surgery.

Patient Signature:

Date Signed:

Email Address:

Date

Your address

Address

City

State / Province

ZIP / Postal code

Signature

Email

Thank you

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