Anatomic and Forensic Pathology Associates
Brain procurement Scope of Services Area of Coverage and Licenses Legal and Financial Requirements An Outline of the Technique Consent Form
E. Olenko MD e-mail

Consent Form

Please fill out this form and then PRINT this page and mail it to the address at the bottom. Unfortunately your physical signature is required, so e-mail submission is not valid.

I, , the and nearest kin of who died on grant Dr. E. Olenko and/or his associate permission to perform an autopsy on the body and the head to include the thoracic, abdominal, cranial cavities, and extremeties of the deceased for the purpose of determining the cause of death and identifying possible relating pathology. I further authorize Dr. E. Olenko to retain for study or otherwise dispose of the tissue and organs derived from this procedure.

I understand that I have the right to refuse to permit this procedure and that by signing this authorization I waive that right. I further understand that I have the right to limit the scope of the autopsy and that any such limitations are described below.

Limitations, if any:

The purpose and scope ot this procedure have been satisfactorily explained to me.

I understand that this autopsy does not include any toxicology test, microbiology test, and special neurological or DNA studies.

Signature of Next-of Kin:________________________
Date:
Time:
Address:
City:
State: ZIP:

Relationship to Deceased:

Signature of Witeness: ________________________

Signature of Interpreter:
(if req'd)
____________________


Brain procurement Scope of Services Area of Coverage and Licenses Legal and Financial Requirements An Outline of the Technique Consent Form