Ronald Levine Medicine Professional Corporation
56 Aberfoyle Crescent, Suite 650
Etobicoke, Ontario, M8X 2W4
416-236-2581

I hereby authorize and direct Ronald H. Levine, M.D., my surgeon, to perform the following operation upon me, consisting generally of the following:

And/or to do any other therapeutic procedure that his judgement may dictate to be advisable for my well-being.

 

The anticipated nature and effect, possible alternative methods of treatment, risks involved and possible complications of what is proposed have been explained to me by Dr. Levine. I am satisfied with these explanations and understand them.

 

I am aware that the results and outcomes of my surgery cannot be precisely predicted and I acknowledge that no guarantees or warranties have been made to me as to such results or cure of my problem(s) to be treated.

 

I consent to be photographed before, during, and after the treatment and that these photographs shall be the property of Dr. R. Levine and may be published in medical journals and/or presented at medical meetings for scientific purposes with the understanding that my name shall not be given in the use of any of these materials.

 

I agree to keep Dr. Levine informed of any change of address so that he can notify me of any late findings, and I agree to co-operate with him in my care after surgery until completely discharged.

 

My signature given below constitutes my acknowledgment (1) that I have read the above consent and fully understand and agree to the foregoing, (2) that the operations or special procedures have been adequately explained to me by Dr. Levine and that I have all the information that I desire, and (3) that I authorize and consent to the performance of the operations or special procedures.