<p> CCHI Mini-Glossary Project Glossary #6 Subject: General Consent (Sight Translation) Language: English</p><p># English Your Translation into: Explanation or acceptable substitution in English 1. General consent</p><p>2. General consent for care</p><p>3. Treatment consent</p><p>4. Acknowledgement form</p><p>5. I certify that…</p><p>6. I have read and fully understand the above statements 7. I consent to … Syn. I give consent to… I grant consent to…</p><p>8. I agree to…</p><p>9. Fully and voluntarily</p><p>10 By signing below… .</p><p>11 I understand and . acknowledge the following… 12 Currently in effect .</p><p>Certification Commission for Healthcare Interpreters (CCHI) 1725 I Street, NW – Suite 300 / Washington DC 20006 www.cchicertification.org / [email protected] 1 CCHI Mini-Glossary Project Glossary #6, Subject: General Consent Language: English</p><p>13 Hereby .</p><p>14 Your signature . indicates full acceptance and acknowledgement of each applicable paragraph marked by an (X). 15 Personal . representative</p><p>16 Authorized . representative</p><p>17 Custodian or Legal . Guardian</p><p>18 Witness .</p><p>19 Relationship to patient .</p><p>20 Self (n) .</p><p>21 The consent will . remain fully effective until it is revoked. 22 This consent is . effective for as long as… 23 In writing .</p><p>24 I have been given… . Syn. I have been provided… I have received… 25 I have been advised . that…</p><p>Certification Commission for Healthcare Interpreters (CCHI) 1725 I Street, NW – Suite 300 / Washington DC 20006 www.cchicertification.org / [email protected] 2 CCHI Mini-Glossary Project Glossary #6, Subject: General Consent Language: English</p><p>26 You have the right to… .</p><p>27 I authorize… .</p><p>28 At any time .</p><p>29 I understand that I am . responsible for…</p><p>30 Surgical, medical or . diagnostic procedure</p><p>31 Risks and hazards . involved</p><p>32 Recommended . treatment</p><p>33 Suggested treatment .</p><p>34 Appropriate treatment .</p><p>35 Necessary treatment .</p><p>36 Reasonable and . necessary </p><p>37 Purpose, potential . risks, and benefits of any test ordered for you 38 Medical examinations, . testing and treatment</p><p>39 Invasive or . interventional procedures</p><p>Certification Commission for Healthcare Interpreters (CCHI) 1725 I Street, NW – Suite 300 / Washington DC 20006 www.cchicertification.org / [email protected] 3 CCHI Mini-Glossary Project Glossary #6, Subject: General Consent Language: English</p><p>40 As deemed necessary . Syn. May deem necessary 41 Prior to .</p><p>42 To renter treatment . Syn. To perform treatment To administer treatment 43 To obtain treatment . Syn. To undergo treatment 44 To discontinue services .</p><p>45 Refusal to grant such . consent will not jeopardize my right to… 46 Permission for . treatment</p><p>47 Conditions of care .</p><p>48 I agree to the terms . specified.</p><p>49 I am authorized to . execute this form.</p><p>50 To facilitate my care .</p><p>Certification Commission for Healthcare Interpreters (CCHI) 1725 I Street, NW – Suite 300 / Washington DC 20006 www.cchicertification.org / [email protected] 4</p>