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TREATMENT CONSENT FORM Patient Name Birthdate Please read and initial the items checked below. Then read and sign the section at the bottom of form. 1. WORKTO BE DONE I understand

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Page 1: TREATMENT CONSENT FORM Patient Name Birthdate Please read and initial the items checked below. Then read and sign the section at the bottom of form. 1. WORKTO BE DONE I understand

Page 2: TREATMENT CONSENT FORM Patient Name Birthdate Please read and initial the items checked below. Then read and sign the section at the bottom of form. 1. WORKTO BE DONE I understand

Page 3: TREATMENT CONSENT FORM Patient Name Birthdate Please read and initial the items checked below. Then read and sign the section at the bottom of form. 1. WORKTO BE DONE I understand

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