Horizon OMS — Surgical Consent

Horizon OMS of Chicago

Surgical Informed Consent

6 E St. Charles Rd, Lombard IL 60148
P: (630) 425-2555 | F: (630) 425-2554
Dr. Ali Al-Qudsi, DMD, FAAOMS, ABOMS

01Patient

02Procedures

03Review & Mark Up

04Sign

Patient full legal name

Date of birth

Provider

Consent date:

Select one or more procedures

Step 1 of 4

Review, mark up & annotate

Select text to red-underline automatically. Tap toolbar to highlight, bold, or add a note.

Mark up the consent as you discuss it with the patient. All markup prints with the document.

⚠️ Minor patient (under 18) — A parent or legal guardian must sign on behalf of the patient. Please update the relationship field below.

Patient signature

Sign with finger or stylus

Doctor / staff signature

Dr. Al-Qudsi / staff — sign here

Relationship to patient

Witness / staff name

Consent date & time:

✓

Email a copy to patient

Sent as a standard, unencrypted email at the patient's request.

Staff Access