Consent Statement

I hereby give my voluntary consent to receive medical examination, diagnosis, and treatment from the healthcare provider and its authorized staff. I understand that:

• The nature and purpose of the treatment have been explained to me.
• I have had the opportunity to ask questions.
• No guarantee or assurance has been made regarding the results of treatment.
• My medical information may be recorded and used for treatment, billing, and healthcare operations while maintaining confidentiality.

I confirm that the information I have provided is accurate to the best of my knowledge.