To the client: You have the right to be informed about the procedure(s) to be administered, including benefits, risks, and potential side-effects, so that you can decide whether to proceed. You are encouraged to ask _________________________ any questions you may have and to consult with a healthcare provider if you have additional questions.

Questionnaire: By signing this authorization form, you declare that the answers given herein are true and complete to the best of your knowledge. False or misleading answers can lead to complications and/or undesirable results.

Please indicate your answer by checking one box per question and provide detail where appropriate.