Dr. Jeffrey Rubin has recommended the procedure named below to treat and/or diagnose the cause for your pain. There is no guarantee that this procedure will provide pain relief. In rare circumstances your pain can worsen even though the procedure is performed without complications.
Alternatives to procedural treatments can include physical therapy, medications, activity modification, exercise program or surgery. The benefits of the procedures are to decrease pain and possibly rule out medical conditions. If I choose not to have recommended procedure, my prognosis (future medical condition) will remain the same.
RISKS: The potential risks associated with each procedure may include (but not limited to): allergic reaction, infection, disfiguring scar, total or partial paralysis, quadriplegia, brain damage, bleeding, increased pain, heart and/or respiratory arrest or death. There is also less than 1:10,000 risk of nerve damage and 1:100 risk of spinal headache and/or spinal fluid leak. Some specific risks are listed below. You will be having the following procedure:
Epidural (Cervical, Thoracic or Lumbar), Transforaminal Epidural, or Lumbar Sympathetic Nerve Block
Specific risks for this/these procedures is/are:low blood pressure, spinal headache requiring epidural blood patch, infection, temporary weakness in the upper or lower extremities, increased blood sugar in diabetics, paralysis, allergies or reactions to medications used.
I understand and acknowledge that by signing this form I am representing in writing that I have been fully informed in general terms to my satisfaction of the following:
- A diagnosis of my condition requiring this procedure
- The nature and purpose of the procedure
- The material risks of the procedure
- The likelihood of success of the procedure
- The practical alternatives to the procedure
Such information was provided through use of videotapes, audiotapes, pamphlets, booklets or other means of communication and through direct conversation with the responsible physician or other healthcare providers under the supervision and control of the responsible physician.
I understand that the physician, medical personnel and other assistants will rely on statements about the patient, patient’s medical history and other information in determining whether to perform the procedure or the course of treatment for the patient’s condition and in recommending the procedure, which has been explained.
I certify that I am not on any blood thinning medications and have not taken any for 7 days prior to the procedure. This includes Coumadin, Aspirin 325mg, Lovenox, Plavix or Aggrenox. Some over the counter medications contain aspirin. Please ask if you are uncertain if you have taken any medication that contains blood-thinning agents. These can cause excessive bleeding and some procedures might need to be cancelled.
For women of childbearing age: I certify that I am not pregnant or breast feeding at this time and that I am aware of the risk of blocks/sedation and fluoroscopy to an unborn child. I further understand that if it is necessary for me to take antibiotics to prevent infection after the procedure, the antibiotics may reduce the effectiveness of oral contraceptives and that, if I am taking oral contraceptives, it will be necessary for me to utilize another method of contraception until my next menstrual cycle.
I understand that the practice of medicine is not an exact science and that NO GUARANTEES OR ASSURANCES HAVE BEEN MADE TO ME concerning the results of this procedure.
BY SIGNING THIS FORM I ACKNOWLEDGE THAT I HAVE READ OR HAD THIS FORM READ AND/OR EXPLAINED TO ME, THAT I FULLY UNDERSTAND ITS CONTENTS, THAT I HAVE BEEN GIVEN AMPLE OPPORTUNITY TO ASK QUESTIONS AND THAT ANY QUESTIONS HAVE BEEN ANSWERED SATISFACTORILY. I HAVE ALSO RECEIVED ADDITIONAL INFORMATION INCLUDING BUT NOT LIMITED TO THE MATERIALS RELATED TO THE PROCEDURES DESCRIBED HEREIN.
I hereby voluntarily request and consent to the performance of the procedure described.