Appendix A
STATUTORY DECLARATION
I , "Lisa Edith Doe of 5 Carol Place Tidy Gardens"
in the state of "Your State" do, on this date ...........................
solemnly and sincerely declare that I fully understand and acknowledge the medical procedures my partner "Jane Doe also of 5 Carol Place Tidy Gardens"
in the state of "Your State" is about to undergo and herein declare I will take no action, Legal or Civil against any person or persons, or against any hospital or its staff who help in the medical procedures, except where genuine malpractice or failure in Duty of Care can be proven beyond doubt.
And I make this solemn declaration conscientiously believing the same to be true and by virtue of the provisions of
"The Oaths Act, 1936."
signed .................................... this day of ............................19.....
Declared and subscribed at ...................................... in the State
of "Your State" this ....................day of.................19.....
before me ..................................................................(usually a Justice for the Peace).
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