CONSENTEMENT ÉCLAIRÉ

THE UNDERSIGNED, GIVE MY FULL AND VOLUNTARY CONSENT TO PERFORM THE SERVICES.

I ACKNOWLEDGE THAT I UNDERSTAND THE NATURE OF THE SERVICE, THE EXPECTED BENEFITS OF THE SERVICE AND THE MATERIAL RISKS AND SIDE EFFECTS OF THE PROPOSED.

I REMAIN FREE TO WITHDRAW MY CONSENT IN WRITTING AT ANY TIME AND THE TREATMENT SHALL CEASE AT SUCH TIME.