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CONSENT / REFUSAL TO EVALUATION BY UCONN MEDICAL STUDENT
Office of Minh Han, MD – Manchester, CT
Date:___________________
Patient’s Name: _________________________________
Patient D.O.B.: _________________________________
Dr. Minh Han, or a clinical staff member, has explained to me that this office supports the
UCONN medical student educational process. As such, I have been given the option of
allowing, or not allowing, a UCONN medical student to participate in my office visit with Dr. Han
today. I understand that Dr. Han will also participate in my evaluation today and that all
medical decisions and treatment plans will be determined by Dr. Han.
Please select ONE of the following responses to this information:
YES – I understand this information I agree to allow a medical student to perform my
initial evaluation today. I further understand that this decision is only in effect for today’s visit
and that I may elect to revoke this choice at any point during today’s visit.
------------------------------------------------------- OR ---------------------------------------------------------------
NO – I understand this information and I have elected not to allow a medical student to
perform my evaluation.
Signature:__________________________________________
(Patient or Legal Representative)
If signed by other than patient, indicate relationship: ________________________________
If signed by someone other than the patient, patient is unable to sign because: ___________
________________________________________________________________________
Effective 11/10/10