Disclosure

Medical Procedure Consent Form

Name: [Patient’s name]

Objective and Description of Treatment: [Described according to the treatment performed]

The treatment is indicated for the following purposes: [Described according to the treatment performed]

Treatment contraindications:

The treatment is NOT indicated for patients who have the following conditions or diseases:  Cancer.

Treatment risks: The risks of treatment depend on the anatomical site, the magnitude of the medical intervention, and the type of treatment the patient receives. The risks that may occur are general discomfort, local pain, limitation in movement, infection, anaphylactic shock, death.

In any case, it is essential to note some consequences that may occur during the development of medical treatment, and the patient must be aware of them, such as: anaphylactic reaction, death.

The doctor will choose the treatment and technique that can achieve the best results, with the least risks and discomfort, based on the information provided by the patient.

**PRIVACY AND CONFIDENTIALITY**

RENUE staff expresses respect for the privacy of your personal data and reaffirms its commitment to maintain the confidentiality of the information you provide in terms of its Privacy Notice and applicable legislation. In the event of using medical, laboratory, or imaging information for educational, research, or marketing purposes exclusively for RENUE's use, it is strictly prohibited to mention the patient's identity to ensure the confidentiality of patient data.

By this act, I hereby declare that I have provided a complete and detailed medical history to RENUEPV, S. DE R.L. DE C.V. ("RENUE"), and that I do not have any of the diseases or conditions mentioned above, or any other disease or condition that I should inform RENUE about.

Furthermore, I hereby acknowledge that RENUE collects progress and patient information and graphically displays the results obtained. There are benefits associated with the various treatments provided by Renue; however, there is no indisputable certainty of these benefits, as Treatments are not an exact science, do not have the same effect on all patients, and there is no guarantee of the exact result thereof. 

I, [Patient’s name] voluntarily accept in full use of my mental faculties and give my consent, therefore the authorization to Doctor (treating physician’s name] to perform: [type or treatment] indicated by [treating physician’s name] with specialty [medical specialty] initiating treatment on [day of the week that patient’s treatment is starting]. 

I have read and understood the information that has been explained regarding consent. I declare that I have been fully informed about the benefits, risks, effects, and possible complications of the treatment described to me, and that all my doubts and questions have been clarified and answered, providing me with enough time for this. Likewise, I understand that I have not been assured or guaranteed that the results of the indicated treatment will achieve the expected benefits, since THERE ARE NO ABSOLUTE GUARANTEES. By signing this, I expressly consent to the application of the treatment that has been sufficiently and understandably explained to me by a physician.

I accept and expressly authorize the professionals of RENUEPV, S. DE R.L. DE C.V. ("Renue") to apply the treatment or additional therapeutic measures that are necessary and convenient for maintaining my health in case of contingencies during the procedure. For educational purposes, to contribute to scientific knowledge, as well as for marketing purposes exclusively for Renue, I also expressly accept and authorize that the anatomical area treated during this procedure be filmed or photographed, but safeguarding my identity and personal data. I understand that at all times there will be prompt communication and a respectful relationship with the physician, whom I have voluntarily sought for professional help.

I declare that I have provided legal and truthful data about the physical and health status of my person that could affect the treatments to be performed on me. I understand the content of this document and in accordance with it, I sign it in duplicate, keeping an original with all the required signatures.

Note to the patient, family member, or legal representative: This Informed Consent Letter may be expressly and unequivocally revoked at any time before the procedure has commenced.