Capsular Contracture Release Consent Form
Please complete this form to confirm your understanding and authorization for the capsular contracture release procedure.
Full Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Procedure Date
*
-
Month
-
Day
Year
Date
Please read the following and acknowledge your understanding and consent for the Capsular Contracture Release procedure. By submitting this form, you confirm that you have had the opportunity to discuss the procedure, understand the risks and benefits, and authorize the treatment.
*
I acknowledge that I have read and understood the information above and consent to the Capsular Contracture Release procedure.
*
I agree and give my consent.
Patient Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit Consent
Submit Consent
Should be Empty: