*If treatment includes sensitive areas, I consent to have the practitioner provide assessment and/or treatment of the areas indicated below: 

I acknowledge the practitioner has explained the following to me:

• the nature of the treatment, as set out above
• if applicable, the clinical reason(s) for the assessment of the above sensitive area(s) and the draping methods to be used the expected benefits of the treatment
• the material risks of the treatment 
• the material side effects of the treatment
• the alternatives to having the treatment 
• the likely consequences of not having the treatment

I acknowledge that my practitioner cannot guarantee the results of the proposed treatment.

I acknowledge that I have informed my practitioner about my relevant health history, including whether I have any allergies, metal implants, if I suffer from any type of major bleeding disorder, if I use a pacemaker, or if I have any infectious viruses or diseases. 

I understand that my consent is voluntary, and I have the right to withdraw my consent to the treatment at any time. 

I understand that the fees charged for my treatment are not covered under OHIP and must be covered in full by myself or through third party insurance. I am responsible for the full and prompt payment after services have been rendered. I acknowledge that my practitioner has explained the applicable fees to me.

I acknowledge that I have discussed the content of this form with my practitioner. I acknowledge that I have asked any questions I may have and received answers I understand.

By signing this form, I give my informed consent for the treatment set out above.

By signing this form, I acknowledge that I have reviewed the form with the patient (or substitute decision-maker) and have answered the patient’s (or substitute decision-maker’s) questions.