Consent For Office Procedures
EVIDENCE OF INFORMED CONSENT TO OPERATION OR OTHER PROCEDURE
I, (patient or guardian), authorize ProvidersLisa Pearson, CRNAGia Forbes, CRNARobert Howell, CRNA and/or their assistants as may selected by him/her to perform the following procedure or operation:
I understand that the procedure is: ProceduresNerve BlockLarge Joint InjectionMedium Joint InjectionSmall Joint InjectionTrigger Point InjectionSympathetic BlockBotox Injection
IF YOU HAVE ANY QUESTIONS AS TO THE RISK OR HAZARDS OF THE PROPOSED SURGERY OR TREATMENT, OR ANY QUESTIONS CONCERNING THE PROPOSED SURGERY OR TREATMENT, ASK YOUR PHYSICIAN NOW, BEFORE SIGNING THIS CONSENT FORM.
DO NOT SIGN UNLESS YOU HAVE READ AND THOROUGHLY UNDERSTAND THIS FORM!
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Document Name: Consent For Office Procedures
Agree & Sign