No guarantee: I understand that no warranty or guarantee has been made to me as to the result of the medical evaluation for services rendered to me or a cure of my medical condition.
Benefits: To have evaluation of my medical condition.
Risks: Just as there may be risks and hazards and continuing the present condition without evaluation, there are also risks and hazards related to the performance of medical studies, medical and/or diagnostic studies planned for me. I understand that common to surgical, medical and/or diagnostic studies, there is the potential for electrical interference of any electronic device that I may have implanted, infection, increase in any of my usual pain usually temporary and brief, blood clots in the veins, bleeding, allergic reactions and even death. These additional risks may require bedrest, or bandages, bloodpatch(s), etc.
Alternatives: Alternative is not to have the study (studies) done.
Photographs: Observers: I consent to the photographing and videotaping or one or the other or both to be performed into the presence of students or other observers present in the study room to observe for the purpose of advancing medical education. I am aware that Dr. Molette has permission or my consent. Any videotaping/photography or other similar documentation, if used, would include appropriate portions of my body for medical, scientific, poor educational purposes. My identity would not be revealed by descriptive text accompanying the pictures.
I have been given an opportunity to ask questions about my conditions, alternative forms of evaluation, risks, and benefits of the planned evaluation (s) and the risk/consequences of study. All questions have been answered to my satisfaction and I amaware that if I have more questions, I may/should ask them at the time of the study (studies). I have sufficient information to give this informed consent. I certify that this form has been fully explained to me. I have read this form or it has been read to me. The blank spaces have been filled in by me or my advocate (legal) and I understand its contents.