Medical Form Encrypted – 2

Medical Questionaire

Your Consent

This is an informed consent document that has been prepared to help inform you concerning your treatment and the risks involved. It is important that you read this information carefully and completely.

Please complete each section, indicating that you have read the page and sign the consent at the bottom prior to your treatment.

RISKS OF TREATMENT: Every procedure involves a certain amount of risk, and it is important that you understand the risks involved. An individual's choice to undergo a procedure is based on the comparison of the risk to potential benefit.

Although the majority of patients do not experience these complications, you should discuss each of them with your practitioner to make sure you understand the risks, potential complications, and consequences of your treatment:
Bleeding, Bruising/Swelling, Infection & Unsatisfactory Outcome/Temporary loss of function of nearby muscles.

PUBLICITY MATERIALS I authorize the taking of clinical photographs and videos. I understand that photographs and video may be taken of me for educational and marketing purposes. I hold the practitioner harmless for any liability resulting from this production. I waive my rights to any royalties, fees and to inspect the finished production as well as advertising materials in conjunction with these photographs.

You certify by signing this form that you have read the information in this document and completely understand it. You choose to proceed based entirely on the information provided in this informed consent document. You have been given all the necessary opportunities for discussion and all your questions regarding your treatment have been answered. You therefore and hereby consent to the care or treatment described herein.