I have been informed about the pros and cons regarding this medical treatment. I do hereby (accept) / (refuse) treatment. Describe treatment: __________________________________________________________________________
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Signed by:_____________________________ Date: _________Time:_______

(If person to receive treatment is under 18 years of age, a parent or guardian must sign this release form.)

Witnessed by:_________________________ Date: _________ Time: _______

Witnessed by:_________________________ Date: _________ Time: _______