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Conflict of Interest - Patient Disclosure Statement (Implantable Device)

As part of your surgery, Dr. _____________________may recommend using an implantable device ____________________ manufactured by the _____________________company.

In the interest of full disclosure, Dr. _____________________wants to make you aware of the fact that he/she serves as a paid consultant to the _____________________ company.

Dr. _____________________is available to talk with you and discuss alternative treatments and products that may be available.

If after discussion you would prefer, for any reason, that a device manufactured by ____________________ not be used in your treatment, please feel free to let Dr. ___________________know.

I have read the above disclosure statement and will voice any concerns that I have to Dr. _____________________or his/her staff.

_______________________________
Patient Signature

_______________________________
Date

PDF Version

Open the Patient Disclosure Statement (Implantable Device) in Adobe Acrobat format.