194 NORTH STREET

DANVERS, MA 01923-1219

1. I,___________________________________________________________,

authorize the performance upon myself of examinations and/or treatments performed by or under the direction of doctors, associates or assistants employed by Comeau Health Care Associates, PC.

2. I also consent to the performance of other diagnostic and therapeutic procedures in addition to, or different from those stated above, whether or not arising from presently unforeseen conditions that the doctors, associates or assistants employed by Comeau Health Care Associates, PC may consider necessary or advisable in the course of my health care.

3. The nature and purpose of the procedures, the possible alternatives, the risks involved, the possible consequences, and the possibility of complication have been explained to me by the doctors, associates or assistants employed by Comeau Health Care Associates, PC.

4. I acknowledge that no guarantee or assurance as to the results that may be obtained from the procedure has been given by the doctors, associates or assistants employed by Comeau Health Care Associates, PC.

Date:____________________________Signed:________________________________

Witness:________________________Relationship:______________________________