Patient Consent to Medical Testing

TO: [Name of Physician] (the "Physician")

AND TO: [Name of Hospital] (the "Hospital")

I, [Name of Patient], hereby acknowledge and agree as follows:

1. I acknowledge that:

(a) I may require medical treatment;

(b) The practice of medicine is not an exact science; and

(c) I have received no guarantees regarding any medical treatment I may receive.

2. I consent to the performance of any tests, examinations and procedures that the
Physician, his or her assistants or his or her designees deems necessary or desirable for
the purposes of assessing my health or the necessity of medical treatment.

3. I authorize the Hospital to release any physicians, hospitals, nursing homes or other
health care institutions that might be involved in my continuing care, any information
deemed necessary or desirable to facilitate this health care.

4. This consent is given freely by me, without any undue influence or impairment of my
faculties.

Dated this _____ day of ____________________, 20_____.

Witness [Name of Patient]