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INFORMED CONSENT FOR PROCEDURE

I, ________________, hereby consent to undergo the medical procedure of:

[Procedure Name in English and Cantonese]

The following risks and benefits have been explained to me in my preferred language (Cantonese) through a certified medical interpreter (ID: INT-7829):

• Risks: Bleeding, infection, allergic reaction, anesthesia complications
• Benefits: Diagnosis, treatment, pain relief, improved quality of life
• Alternatives available: No treatment, medication, other procedures

I understand that I may withdraw consent at any time before or during the procedure.

NOTICE OF PRIVACY PRACTICES (HIPAA)

I acknowledge that I have received and understand the Notice of Privacy Practices, which explains how my protected health information (PHI) may be used and disclosed.

Interpreter Statement: I have accurately interpreted all HIPAA privacy information to the patient in Cantonese to the best of my ability.