2. I recognize that during the course of the procedure/treatment unforeseen conditions may necessitate different procedures than those above. I therefore authorize the above physician and/or assistants or designees to perform such other procedures that are in the exercise of his or her professional judgement necessary and desirable. The authority granted under this paragraph shall include all conditions that require treatment and are not known to my physician at the time the procedure is begun.
3. As part of the requirements of the Amenity Day Spa, my chart may be subject to a peer review for quality control.
4. I acknowledge that no guarantee has been given by anyone as to the results that may be obtained.
5. I consent to the photographing or televising of the procedure(s) to be performed, including appropriate portions of my body, for medical, scientific or educational purposes, provided they do not reveal my identity. These photographs and videos may be used for medical meetings, advertising, or any promotional or public relations purposes.
6. For purposes of advancing medical education, I consent to the admittance of observers to the treatment room.
7. I understand that the signature of the witness (if a non-physician) on this document indicates only that the signing of my name has been observed and not that the witness has necessarily provided information regarding the procedure.
IT HAS BEEN EXPLAINED TO BE MY PHYSICIAN AND/OR ASSISTANTS IN A WAY THAT I UNDERSTAND: i. THE ABOVE TREATMENT OR PROCEDURE TO BE UNDERTAKEN
ii. THERE MAY BE ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT
iii. THERE ARE RISKS TO THE PROCEDURE/TREATMENT PROPOSED
I CONSENT TO THE PROCEDURE AND/OR TREATMENT AND THE ABOVE LISTED ITEMS (1-9).
I AM SATISFIED WITH THE EXPLANATION.
