SAN ANDREAS DEPARTMENT OF HEALTH

PATIENT CONSENT FORM

Los Santos, 30 September 2023

Patient Name : Garnadoel Airmoney

Date of Birth : 27-09-1995
Gender : Male
Name of Patient Representative : Youngluxs
Contact Number : 304455566

Treatment and Services:

You have been informed about the specific medical treatment or healthcare services that will
be provided to the patient by the San Andreas Department of Health. This may include, but is
not limited to, consultations, examinations, tests, procedures, surgeries, medications,
therapies, and follow-up care.

Purpose and Risks:

You understand that the purpose of the treatment or services is to address patient medical
conditions and improve patient health. You have been informed about the potential risks,
benefits, and alternatives associated with the proposed treatment or services. It is important to
note that every medical intervention carries some level of risk, and potential outcomes cannot
be guaranteed.

Dispute Resolution:
In the event of any disputes or disagreements arising from patient treatment, you agree to
engage in good faith discussions with San Andreas Department of Health to resolve the
matter amicably.

Consent:
By signing below, you acknowledge that you have read, understood, and voluntarily agree to
the terms and conditions stated in this Patient Consent Form.

Healthcare Provider’s Name :

@902 Shailene Cooper
Signature

Healthcare Provider Patient / Patient Representative