I hereby give my permission and consent for Gary Bucher M.D. & Associates to treat me using generally accepted standards of medical care. I am aware that medicine and surgery are not exact sciences and no guarantee for successful outcome has been made or implied to me. I understand that treatment for my condition(s) will be based upon the information that I provide. I also understand that the High Resolution Anoscopy (HRA), which is the examination and evaluation of my anal canal, is considered a surgical procedure. You are being seen by our providers because your doctor has referred you to us and/or because you are experiencing symptoms that could be related to Anal Dysplasia. Your visit with Gary  Bucher M.D. & Associates is not part of your preventive health benefit.  I assume full responsibility should I provide inaccurate, incomplete or misleading information.

I certify that the identifying information, addresses, telephone information, and e-mail address that I have provided is correct.

I certify that the insurance information that I provided is correct and up to date.

I agree to inform Gary Bucher M.D. & Associates if such information changes or becomes outdated. I understand that the office of Gary Bucher M.D. & Associates cannot contact me if I have provided incorrect or illegible information or should I not keep this information current and correct.