APPENDIX 3 ADULTS WITH INCAPACITY (SCOTLAND) ACT 2000 Report on Section 50 Second Opinion Visit by: Medical Practitioner primarily responsible for treatment: Name and role of person authorised to consent

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KIPE COPYRIGHT AND CONSENT FORM To ensure uniformity of treatment among all contributors, other forms may not be substituted for this form nor may any wording of the form be changed. This form is intended for original ma

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Patient Consent to Treatment Form Pure Health Wellness Clinic Leena Kim Naturopathic Doctor 219 Roncesvalles Avenue, Toronto, ON M6R 2L6 PATIENT CONSENT TO TREATMENT FORM

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Withdrawal of consent for your saved sample Certain samples are routinely saved in order to be useful for your future care, diagnostics and treatment. The samples can also be of great value to medical research. All resea

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CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS Patient Name: ______________________________________________________ DOB: ____________________Account: ____________

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INFORMED CONSENT FOR ANESTHESIA Anesthesia for Dentistry, Lynn E. Thompson, D.D.S., F.A.D.S.A. The following is provided to inform patients of the choices and risks involved with having treatment under anesthesia. This

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UNIVERSITY OF WASHINGTON ACKNOWLEDGMENT OF RISK AND CONSENT FOR TREATMENT FOR ADULT FIELD TRIP PARTICIPANTS Section 1 (To be completed by field trip leader) Class: Day Trip to Mt. St Helens Field trip leader: Robert Wing

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AUTHORIZATION TO USE CASE/INTERVIEW MATERIALS FOR PUBLICATION AND RESEARCH THIS IS A CONSENT AND RELEASE -- PLEASE READ CAREFULLY. Thank you for allowing me to use case material from your psychological treatment/interv

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