Given the above,   I the undersigned …………………………………..………… born to ………………………….………… I declare to have been invited to read very carefully what is reported in this paper which corresponds, moreover, to what has been amply explained to me, by Prof/Dr. ……………………………………………………………. I also declare that I have understood the meaning of what I was exposed to, that I do not need further clarification and therefore knowingly   - I agree □ - I do not agree □ to submit to the proposed procedure;   Date…………………………….   The Patient signature                           The Doctor   _______________________                         _______________________