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North Shore LIJ Lenox Hill Hospital 100 East 77th Street New York NY 10075-1850 210 East 64th Street New York NY 10065-7471 CONSENT TO SURGICAL PROCEDURE INVASIVE TEST PROCEDURE TREATMENT and/or ANESTHESIA I hereby authorize Dr. I have crossed out any paragraphs or words above which do not pertain to me. Patient/Healthcare Agent/Guardian/Next-of-kin Signature Print Name Date/Time Relationship if signed by other than patient Witness Interpreter Physician/Practitioner Certification I hereby...
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