Consent form for Outpatient Services

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Consent - Outpatient Services
I consent to the services that I have selected below. This procedure will be done by a licensed nurse who is trained in all procedures listed above. If at any time, a determination is made that the procedure is outside of the conditions of safety, it may be discontinued.

The purpose and nature of the procedure and its potential benefits and risks have been explained to me. I am aware that there may be other risks or complications not discussed that may occur. I also understand that during the course of the proposed procedure, unforeseen conditions may be revealed requiring the performance of additional procedures, and I authorize such procedures to be performed. I acknowledge that no guarantees or promises have been made to me concerning the results of this procedure or any treatment that may be required as a result of this procedure.


Payment is due before the service can be administered. There has been no representation that this procedure is covered under my insurance plan or that I can/should seek such reimbursement. I agree to pay the full cost of the service regardless if the catheter insertion is canceled or is stopped at any time prior to completion at the discretion of the technician/nurse/clinical assistant or myself. I understand that I am responsible for the full cost of the procedure and agree to pay.

I authorize and consent to the performance of the procedure(s).

I hereby declare that I have read and understood what is stated here, and that I fully understand the risks of the abovementioned procedure since they were shared in a language that I can understand. I have been given the
opportunity to ask questions and I voluntarily consent to the performance of the procedure.

Full Name
Full Name
Type of Service/s