Physicians Surgery Center of Tempe

Patient Label

Informed Consent for Procedure & Minimal Sedation

I authorize and/or such associates or assistants whom may be designated to perform the following procedure(s):

I recognize that I may withdraw my consent for this at any time. I consent to the performance of operations, procedures, and services such as radiology in addition to or different from those now contemplated, which the above named doctor or his associates or assistants may consider necessary or advisable for my well being during the course of the operation / procedure. I consent to the administration of such IV minimal sedation or other medications as may be considered necessary or advisable. As in any medical procedure, there are risks involved in receiving minimal sedation. Although, serious problems are infrequent, they may occur. The attempt is made to minimize any of the following risks. These risks include, but are not limited to the following: Allergic reactions to any of the medications used, discomfort or bruising at the site where the IV catheter is inserted, vein irritation (called phlebitis), hand/arm motion may be restricted temporarily and further medication or care may be required, nausea and vomiting may also occur, depressed respirations where it may become necessary for intubation or placement of breathing tube, brain damage, stroke, heart attack, or death. These operations and procedures may all involve risks of unsuccessful results, complications, injury or even death, from both known and unknown causes, and no warranty or guarantee if made as to result or cure, and in rare cases it could become worse, even when the procedure if performs in a technically perfect manner. The degree and duration of pain relief varies from person to person. After the procedure the physician will reevaluate your progress, then determine if further treatment procedural risks. Tell the physicians if you are taking any “blood thinners” such as aspirin, Coumadin / Warfarin, Lovenox, Plavix, or Heparin, as these can cause excessive bleeding and increased procedural risks. Specific risks pertaining to each specific procedure are as follows (patient to initial line of procedure):

Lumber epidural (Transforminal, Interlaminar, or Caudal), Spinal Cord Simulator Trial or Placement: Infection including Lumbar, Thoracic, or Cervical Facet Joint or Medial Branch Block, meningitis or arachnoiditis necessitating removal of the device Sacroiliac Joint, Selective nerve Root or Lumbar Sympathetic possible surgical intervention and long-term antibiotics, spinal cord Injection/Block/Ablation (RF): Low Blood pressure, temporary injury, headache requiring epidural blood patch weak/numb arm or leg, Headache requiring epidural blood patch, Vertebroplasty: Pulmonary embolism resulting in breathing problems Neuroma formation (with ablation) and possible death, spinal cord injury, possible need for immediate surgery and / or paralysis Cervical or Thoracic Transforaminal or Interlaminar Epidural, Atlantoaxial Joint, Trigger Point Injection, Occipital Nerve Block, Intercostals nerve Or Atlantooccioital joint injections: Low blood pressure, temporary Block / Ablation: Air in lung requiring chest tube in hospital, local weak/numb arm headache requiring epidural blood patch, seizure, pain from tissue and / or nerve irritation, dimpling or depression of spinal cord or brain stem injury resulting in paralysis or death, Air the skin. in lung requiring chest tube in hospital (Thoracic procedures only). Joint or Bursa Injection: Infection in the joint requiring long-term Discogram, Intradiscal Steroid Injection or Intradiscal Electro thermal antibiotics or surgery, joint swelling and pain (if injected with Anuloplasty (IDET): Infection, or discitis, disc herniation Synvisc), early cartilage degeneration (if injected with steroid), tendon rupture.

The incidence of serious complications listed above requiring treatment is very low (less than 1% in our experience). Your physicians believe the benefits of the procedure outweigh its risks, and it is your decision and right to accept or decline to have the procedure done. I confirm the following: that my physician has explained to me the nature, purpose, and possible consequences of each operation or procedure as well as risks involved, possible complications and possible alternative methods of treatment; that I understand that the explanation I have received is not exhaustive and that other, more remote risks and consequences may arise; that I have been advised that a more detailed and completed explanation of any of the foregoing matters shall be given to me if I so desire; that I do not desire such further explanation; and that I acknowledge that I have received no guarantees, warrantees or assurances from anyone as to the results that may be obtained. I understand that one or more of the physicians providing my treatment may have an ownership interest in this facility.

I have a responsible adult to drive me home. I have not eaten or drank since:

I decline offered minimal sedation: (Patient & Witness Initial) Patient Signature Date/Time

(If patient is unable to sign, state reason) Signature of Legally Authorized Representative Relationship to Patient

Witness Signature Date / Time

Physician’s Statement I certify that I and/or my assistant have informed the above named patient of the following: the nature, purpose, and possible consequences of the operation or procedure, risks involved, possibilities of complications, and possible alternative methods of treatment. All the patient’s questions have been answered. To the best of my knowledge, the patient has been adequately informed.

Physician Signature Date / Time