Patient Information and Consent for Medical/Laser Treatment
My signature below constitutes my acknowledgment that I, _____________________________,
(Print Name)
am a competent, consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further, that I:
have read and understand the information provided in this form;
have had my procedure adequately explained to me by my clinician;
have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction;
have received all of the information I desire concerning my procedure;
consent to photographs of the treatment area;
understand all post treatment recommendations and agree to adhere to them;
freely assume any risks of complications or injury from known or unknown causes associated with, relating to, or otherwise arising out of this procedure;
have the right to consent to or refuse any proposed procedure at any time prior to its performance;
must notify the clinician if my medical history changes prior to subsequent treatments;
Consent to, and authorize Radiological Imaging of Oklahoma dba Tulsa Vein Specialists and Michael Lawless, M.D., George Lyons, M.D., W. Jordan Taylor, M.D., Tom White, M.D.to perform the laser treatment for ________________________________________ (Print Name of Laser Procedure to Be Done)
Signature _______________________________________________________ _______ (Patient, or if under 18, signature of parent/guardian) Date
Printed name of signatory: _________________________________
If signed by other than patient, indicate relationship: _______________________________
Witness: ____________________________________ ________________________ ______
Signature Printed name Date
