Consent to Operation

Dr. Timothy L. Gardner, DPM

Please correct the errors described below.

1. I hereby authorize Dr. Gardner and whomever he may designate as his assistants to perform the following operation:

on the left/right foot.

2. The nature and purpose of the operation, possible alternative methods of treatment, the risks involved, and the possibility of complications have been explained to me. I acknowledge that no guarantee has been made to me as to the results that may be obtained.

3. If any conditions are revealed to Dr. Gardner or any physician/assistant involved at the time of the procedure which were not recognized before the procedure started and which call for procedures in addition to those originally contemplated, I authorize the performance of such procedures in accordance with the judgment of Dr. Gardner or any physician involved.

4. I consent to the administration of anesthesia to be applied by or under the direction of Dr. Gardner and to the use of such anesthetics, as he may deem necessary.

5. I consent to the disposal and/or pathology, if needed, of any tissue and/or parts, which may be removed during the surgical procedure.

7. I understand that the use of drugs, prescribed or otherwise, the abuse of same (both past and present) or the existence of medical conditions not disclosed by myself to Dr. Gardner or his assistants may affect his recommendation as to treatment or alternative forms of treatment and |assume all risks which may exist as a result of my failure of refusal to disclose such matters prior to treatment.

8. I certify that I have read and fully understand the above consent to operation, that the explanations therein referred to were made, and that all blanks or statements requiring insertion or completion were filled in and inapplicable paragraphs, if any, were stricken in my presence and before I signed.

I hereby request medical treatment and authorize payment to Dr. Timothy L. Gardner, DPM.

I understand that I am responsible for any portion of my bill not covered by my insurance company and give Dr. Gardner's office the right to collect my balance within 90 days or I understand that I will be sent to a collections agency and possibly face legal action.

Disclaimer: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.