The following has been discussed with me by the physician performing my procedure:

• The nature and purpose of the proposed procedure.
• The risks of the procedure.
• The possibility or likely consequences/ risks of the procedure.
• All feasible or alternative treatments.

I understand that this request for or consent to procedure above shall be valid for the responsible physician, all medical personnel under the direct supervision and control of the physician, and other medical personnel otherwise involved in this course of treatment.

I acknowledge that I have been given ample opportunity to ask questions and that any questions I did ask have been explained to me in a satisfactory manner.

By signing below, I acknowledge that I have read this form or had this form read/explained to me and that I fully understand this form.