This document is a medical consent form used to obtain patient consent for medical treatment. It outlines the patient's information, medical provider's information, emergency contact details, and explicitly states the risks associated with the treatment. It is used to ensure that the patient acknowledges these risks and agrees to the treatment without any guarantees of results. Additionally, it covers the consent for sharing personal data for specified purposes. The form must be signed by both the patient and the medical provider to confirm agreement to the terms.