Electrophysiology Study / Cardiac Ablation

I authorize and direct Brett Gidney, M.D., with associates or assistants of his or her choice, to perform the procedure of Electrophysiology Study/ Catheter Ablation on:
Name

First Name Last Name
Email
example@example.com
Phone Number

- Area Code Phone Number
I further authorize the physician(s) and assistants to do any other procedure that in their judgment may be necessary or advisable should unforeseen circumstances arise during the procedure.

Please sign using your finger or cursor. Clear
Date

- Month - Day Year
Date
Should be Empty:

State Of The Art