Pap Smear Consent Form

Patient’s Name:

File No.:

DOB:

Mobile Number:

Visit Date:

Registration Time:

Doctor Name:

Pap Smear Consent Form

I, the undersigned patient, hereby authorize the healthcare provider named below to perform a Pap smear as part of my medical care. I understand the purpose, procedure, and potential risks associated with this test, and I have had the opportunity to ask any questions I may have regarding it.

I Dr. certify that I have discussed concerned and have answered all her questions regarding pap smear. I believe that she fully understands what I explained and answered.

I understand and agree that I am financially responsible for the payment I made for that any amount I paid for the sessions or procedures I booked it will only be valid up to 3 months from the date I made the payment. I understand that I need to utilize the sessions or procedures within 3 months period. I agree that my payment made is non-refundable or non-transferable post this period.

أقر بأنني قرأت وفهمت تمامًا جميع النقاط الواردة في هذه الموافقة وأنني جميعها تم الرد على الأسئلة بما يرضيني وأتحمل المسؤولية الكاملة عن ذلك القرار في هذه الموافقة.

Patient Name & Signature :

Doctor/Therapist Name & Signature :

Witness Name & Signature :

Parent or Gaurdian Name (if patient is minor) :

Date :