Consent to Treatment
This Consent to Treatment form is governed by the laws of [State Name].
By signing this consent form, you agree to the following:
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I, [Participant's Name], born on [Date of Birth], reside at [Address] (the "Participant"), hereby consent to receive medical treatment from [Provider's Name], located at [Provider's Address].
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I understand that the treatment may involve [Describe Treatment] and that this treatment has been explained to me, including potential risks and benefits.
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I have had the opportunity to ask questions regarding the treatment, and my questions have been answered to my satisfaction.
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I acknowledge that I may withdraw my consent at any time before the treatment takes place without affecting my right to receive future care.
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I certify that I am an adult of sound mind and I have the capacity to give this consent.
Sign below to indicate your agreement with the above statements:
Participant's Signature: _______________________
Date: _______________________
Provider's Signature: _______________________
Date: _______________________
If you have any questions regarding this consent form, please contact [Provider's Contact Information].