To whom it may concern:

With full understanding of the risks involved in the use of Reprocessed Single Use Devices;

I, __________________________________________________

Patients's Name

__________________________________________________
Patients's Name

__________________________________________________
Patients's or Guardian's Signature

__________________________________________________
Date

__________________________________________________
Guardian's Name

__________________________________________________
Permanent Address

__________________________________________________
City

__________________________________________________
State/Province

__________________________________________________
Zip Code

__________________________________________________
Country (if outside US)

__________________________________________________
Phone