TREATMENT CONSENT FORM

I/we understand the following:
• That I/we have been fully informed about the nature of the treatment, the risks and benefits, and the available treatment options, including
• That I/we have had the opportunity to have all questions answered to my/our satisfaction.
• That this consent is given voluntarily.
• That I am legally competent and have the authority to provide consent for treatment.
• That I have the right to withdraw m y consent for this treatment at any time.
• That withdrawing consent for this treatment will not prejudice my continued treatment
relationship.