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I, ______________________________ (Name), being a patient at _________________ (Hospital), having been fully informed by Dr. ________________________________, a physician and surgeon, of the risks and possible consequences involved in certain medical and surgical treatment consisting of _________________________________, hereby consent to and authorize the administration and performance of such treatment and operation at _____________________________ (Hospital), including the arrangements for anesthesia, except _____________________ (Spinal Anesthesia or as the case may be), and any preliminary, further, or additional treatments and operations, tests, transfusions, injections that may be, in the judgment of Dr. _________________, or any other physician and surgeon associated with or by Dr. ____________________, considered or deemed advisable or necessary at the time the contemplated treatment or operation is being performed.


My intention is to grant full authority to such physicians and surgeons and ________________________________ (Hospital), and their respective employees and assistants, to administer and perform all and any drugs, treatments, tests, or diagnostic procedures to or on me that may be deemed advisable or necessary by the designated physician or surgeon, or any physicians or surgeons associated with Dr. ____________,

or anyone acting under their instructions.




___________________________                                             ____________________

Signature of Patient or Person Authorized                  Date

to Consent For Patient




Relationship to Patient



___________________________                                             ____________________

Witness                                                                                            Date



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