Case Note With Consent Unified Patient Consent, Financial Responsibility & Indemnity AgreementDoctor case Note Patient Name * Email * Phone * WhatsApp Number (Optional) Branch * Ikosi KetuLagos IslandOpebi Ikeja Patient Type * REGISTEREDNOT REGISTEREDFAMILY REGHMOPREVIOUSLY REGISTEREDSPECIAL COUPON HMO Name Date of Visit * Time Of Visit * Patient Acknowledgment * I acknowledge and consent that my wet-ink signature shall be scanned, digitized, and uploaded to all relevant sections of my declaration of consent and clinic records, and shall be treated as an original for all legal and clinical purposes. By ticking acknowledgment on the registration platform and signing at the Clinic, I confirm that I have read, understood, and accepted **Clauses 1–30**, including **Service Operations Charge (SOC)** and **Clinic Policies**. If you are human, leave this field blank. Generate Case Note
