DISCLOSURE AND CONSENT FORM - MEDICAL AND SURGICAL PROCEDURES

To the Patient: You have the right as a patient to be informed about your condition and the recommended surgical or diagnostic procedure to be used so that you may make the decision whether or not to undergo the procedure after knowing the risk and hazards involved. This disclosure is not meant to scare or alarm you, it is simply an effort to make you better informed so you may give or withhold your consent to the procedure.

I voluntarily request Western Wake Wellness as my physician and such associates technical assistants sand other health care providers as they may deem necessary to treat my condition which has been explained to me as:

I understand that the following surgical, medical and or diagnostic procedures are planned for me and I Voluntarily consent and authorize the following Procedure(s):

I understand that my physician may discover other or different conditions which require additionally or different procedure than those planned. I authorize my physician and such associates, technical assistants and other health care providers to perform such other procedures which are advisable in their professional judgement.
I understand that no warranty or guarantee has been made to me as to result or cure.
Just as there may be risks and hazards in continuing my present condition without treatment there are also risks and hazards related to the performance of the surgical, medical and or diagnostic procedure(s) planned for me. I realize that common to surgical medical and/or diagnostic procedure(s) is the potential for infection, blood clots sin veins and lungs, hemorrhage, allergic reactions, scarring and even death. I also realize that the following risks and hazards may occur in connection with this particular procedure:

I have been given the opportunity to ask questions about my condition, alternative forms of treatment, risks of non-treatment, the procedure(s) to be used and the risks and hazards involved and I believe that I have sufficient information to give this informed consent.
I certify that this form has been fully explained to me. That I have read it or have had it read to me. That the blank spaces have been filled in and that I understand its contents.