Informed consent for treatment/diagnostic Testing
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor's office of any changes in my medical status. I certify that I am the patient or legal guardian of the above listed patient. I authorize this office and its staff to examine and treat my condition as the medical professionals see fit, including having diagnostic x-ray examination if necessary.