Online Medical Consent Form
Patient Information
Name
Age
Date of Birth
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Month
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Day
Year
Gender
Please Select
Male
Female
Email
Phone Number
Parent/Guardian or Emergency Contact Details
Contact Person Name
Primary Phone Number
Secondary Phone Number
Acknowledgment, Authorization and Waiver
I authorize Dr. Wolfe with Motion Foot and Ankle - A Division of Modern Medical Group to perform the treatment or necessary procedure listed below:
I confirm that the doctors explained the procedure thoroughly to me and how it will help me with my current condition.
I authorize the use of anesthesia and understands the side effects I can experience from it.
I understand there are post-procedure instructions which I will need to follow for recovery. I understand the risk and complications resulting in adverse events if I do not follow the instructions given to me after the procedure which involves post-treatment care and follow-ups appointments.
I acknowledge that all information I provided in this form is true and accurate.
Right to Withdraw: I understand that I have the right to withdraw my consent and refuse the procedure at any time before it is performed, without affecting my future care.
Consent Statement: I have read and understood the information provided above. I have had the opportunity to ask questions, and my questions have been answered to my satisfaction. I understand the nature, purpose, risks, and potential complications of the procedure, and I voluntarily agree to proceed with the procedure.
Patient/Parent/Guardian Signature
Date Signed
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Month
-
Day
Year
Name
First Name
Last Name
Submit
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