Thyroid Procedure Consent Form
Please review the information below and provide your consent for the thyroid procedure.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please review and acknowledge the following information regarding your thyroid procedure:
- The nature and purpose of the thyroid procedure have been explained to me.
- I have been informed about possible risks, benefits, and alternatives.
- I have had the opportunity to ask questions and all my questions have been answered satisfactorily.
- I understand that I can withdraw my consent at any time before the procedure.
By signing below, I acknowledge that I have read and understood the above information and voluntarily consent to proceed.
Date of Consent
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional Comments or Questions (optional)
Signature of Patient or Legal Guardian
*
Submit Consent
Submit Consent
Should be Empty: