Cosmetic Surgery Consent to Treatment
Patient Information
Full Name
Date of Birth
Procedure
Name of Procedure
Brief Description of Procedure
Risks and Complications
Describe Possible Risks & Complications
Alternatives
Alternative Treatments Discussed
Consent
I confirm that I have discussed the procedure, risks, benefits, and alternatives with my physician.
All of my questions have been answered to my satisfaction.
I give my voluntary consent to undergo this procedure.
Signature
Patient Signature
Date
Physician Signature
Date