My physican/ Surgeon: Dr. Janet Baatile- Ajrouche 

I consent to my physician and the additional practitioner (the practitioner(s) listed above) performing the procedure planned. I also consent to the facility staff doing the things they routinely do before, during and after the procedure(s).

Before I signed this form, an explanation was provided to me by my physician of the anticipated benefits, the likelihood of
success, and potential risks, side effects, and complications of the procedure(s).

I understand what is expected and what may happen after the procedure when I am recovering. I also was informed of the significant alternatives and their
associated risks, benefits and side effects, and the probable consequences of not having the procedure(s) performed.

No guarantees, promises, or assurances have been made to me about the results that may be obtained or the consequences
that may follow the procedure(s).

I understand that before, during, and following the procedure(s), unexpected conditions may be revealed or develop. Under these circumstances, I authorize the physicians and facility staff to exercise their professional judgment in modifying these procedures or doing other procedures they consider advisable and necessary.

I also authorize the performance by qualified persons of services that are deemed necessary including, but not limited to, such services as anesthesiology, radiology, cardiology, intensive care, and others.

I understand that tissues, specimens, parts, organs, devices, or foreign objects may be removed from my body. I claim no
interest in these things and consent to the facility either keeping them or disposing of them under facility policy.

I consent to observers such as students or medical device representatives to be present before, during and after the
procedure(s) for medical, scientific or educational purposes.

I consent to the photographing, filming, recording, or televising of the procedure to be performed, including appropriate
portions of my body for medical, scientific research, or educational purposes.

 I have read or had read to me and fully understand this consent. I have had the opportunity to ask questions. All my
questions have been answered.

CONSENT OF PATIENT ADVOCATE, LEGAL GUARDIAN, OR NEAREST RELATIVE
IF PATIENT IS UNABLE TO SIGN OR IS A MINOR