• I am hereby requesting the following procedure

  • DR. has provided me with the reason for this procedure(s), common risks, and common alternatives.

    More information is available on WWW.LAINTEGRATIVEGI.COM about consent, disclosure, and disclaimers related to these procedures.

    I have been given “The Advance Payment Option” form.

    I have been given “The Pre-Procedure Preparation” form.

    I may ask any question prior to my Procedure Date by contacting the practice.

  • Date Format: MM slash DD slash YYYY