&ere$y agrees to $e ta'en medi#al / surgery : ……………………………………………………………. ……………………………………………………………. () the paent with / without general anesthesia / lo#al. I ma'e this statement with the )a#t that : *. 0,planaon has $een gi1en $y the do#tor a$out the paents disease- treatment oponsand medi#al a#on / treatment as well as the dangers- ris's- and possi$ilies )or a#on arising )rom the medi#al- and )ully understood understood the e,planaon gi1en $y the do#tor. do#tor. 2...................... / inials 3 +. I also agreed ag reed to do )urther medi#al treatment- i) ne#essary )or the paents sa)ety. sa)ety. 2………………………. / inials3