I. SURGEON / PROCEDURALIST / ANESTHESIOLOGIST

We, the undersigned, hereby acknowledge and agree to the following:

We have provided sufficient time for the patient/their representative to ask questions related to the surgery/procedure/anesthesia or any other concerns, and we have answered all such questions. We commit to treating the patient with full professional ethics, responsibility, and the best knowledge, expertise, and available resources of:

to achieve the best possible outcome for the patient.

II. PATIENT / PATIENT'S REPRESENTATIVE

I have been informed and have discussed with the doctors all information regarding the surgery/procedure/anesthesia, including the common risks that may occur.

and the expected success rate. I understand the reason for performing the surgery/procedure/anesthesia and agree to allow the doctors to proceed for myself or my family member.

I have been informed about the estimated costs, including surgical fee, procedural fee, anesthesia fee, and medical consumables. I agree to pay all medical expenses not covered by health insurance or outside the reimbursable scope as required by law and clinic policy.

I agree to allow the doctors to perform any necessary surgery/procedure/anesthesia/examination/treatment if required to save life or prevent serious harm to my or my family member's health.

will perform with full ethics, responsibility, expertise, and available resources to provide the best outcome. However, no doctor can guarantee that surgery/procedure will always improve the condition or prevent deterioration.

I have read this consent form with a clear, sound mind. I fully understand the information explained to me regarding the surgery/procedure/anesthesia. I take full responsibility for my decision to consent to the surgery/procedure for myself or my family member.

After being informed of the condition, risks of delaying or refusing surgery/procedure/anesthesia, and potential complications, I voluntarily declare the following:

III. SIGNATURES