Consent Form for Dilation and Curettage (D&C)

Name:                                                          

Resident Registration Number:                                  

Address:                                                       

I hereby request a dilation and curettage (D&C) procedure due to personal reasons.

I have discussed this decision with my guardian (                         ) 

and have agreed to proceed with the surgery.

Date of Signature:                              

Applicant:                              (Signature)

Guardian’s Name:                       (Signature)

Guardian’s Resident Registration Number:              

Guardian’s Phone Number:                            

To: Director of WOOLEE Obstetrics & Gynecology Clinic