Consent to Treat Form Consent to Treatment Form Patient Name” * I HAVE READ AND UNDERSTAND THE CONSENT TO TREAT AND CHOOSE TO BE TREATED BY A LICENSED MEDICAL VOLUNTEER, UNDERSTANDING THE LIMITATIONS ON THE RECOVERY OF DAMAGES DESCRIBED ABOVE FOR: * Patient I am the Parent/Guardian for the patient: I am the Parent/Guardian for the patient: Patient or Parent/Guardian Signature Acknowledgment: * Clear Date Acknowledgment Signed: * reCAPTCHA If you are human, leave this field blank. Submit Δ