I recognize that this questionnaire is a form with which the surgeon has a better perspective on the status of a patient, and serves as the basis for making a presumptive diagnosis, and give an estimated surgical plan and estimate on the procedures to be performed. I recognize that this or no form can replace the personal medical evaluation, so I understand that there may be differences between this pre-assessment and the definitive evaluation. I accept that I am responsible for the veracity of information provided, and that the alteration or omission of any of the requested data, completely invalidates the questionnaire, and thus, invalidates any presumptive diagnosis and quotation derived therefrom.