Medical Treatment Form

I have discussed my present condition and the various ways it may be treated with

You and the doctor have agreed on the following method of management:

The doctor has discussed with the following:

• The nature and purpose of the treatment
• Additional methods of management that may be necessary if something unexpected happens
• The complications that may occur
• That the outcome of a method of medical management can never be absolutely guaranteed, even though it is carried out with due care

As a result of these discussions:

• I understand the nature and purpose of the treatment
• I understand that undergoing the method of treatment carries risks
• I have had the opportunity to ask questions and have been satisfied with the explanations and answers
• I have discussed alternatives to this method of treatment and have chosen to proceed with this method
• In the event of tissues being removed from my body, I understand that my tissue will be used for diagnostic and treatment purposes. I understand that it will be kept and may be used for ethically approved research, education and laboratory quality procedures

I have been informed of the following equipment costs:

• Total out of pocket cost start from $100

I also consent to the administration of local anaesthetic or other products necessary in the administration of this management.