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Diagnosis

Procedure

In conjunction with the procedure identified above, I understand the following:

Nature and purpose of procedure:

Material risks of procedure:

Likelihood of success:
 Good Fair Poor

Consent:

The procedure identified above has been explained to me, the material risks have been described, and all of my questions have been answered. I acknowledge that no guarantees have been made concerning the outcome of the procedure. I hereby consent to the performance of this procedure by

surgeon Dr:

and I also consent to the administration of anesthesia by

anesthesiologist Dr:

When the patient is less than 18 years of age, a parent or guardian may consent for a minor

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