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I authorize my physician to administer local anesthesia and administer anesthetic medications/drug.

Type of Anesthesia:

CONSCIOUS SEDATION (Level II) is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

Expected Results: Reduced anxiety and pain, partial or total amnesia.

Technique: Drug injected into the bloodstream or by other routes producing a semi-conscious state.

Risks: These may include, but are not limited to; swelling, bleeding or discomfort at the site of injection; phlebitis or other damage to blood vessels; nerve damage; allergic reactions to the anesthetic agents; memory dysfunction/memory loss; nausea and vomiting; dental trauma including but not limited to broken/loose teeth; and prolonged recovery from anesthesia. There is also a rare potential for serious harm, including difficulty breathing, permanent organ damage, cardiac arrest and death.

I authorize the physician, and / or associate, to perform such extension of the procedures(s) described above that they, in the exercise of their professional judgment, determine to be necessary in the event other conditions become apparent during anesthesia, sedation, or during the procedure(s) specifically authorized above. This authority includes treating conditions whether or not they were previously known or foreseen.

In discussion with the Dr. Richardson, I have been informed of and understand:
    1.The benefits, risks and complications of this specific procedure(s).
    2.That there are significant risks such as severe loss of blood, infection, perforation/tear, and cardiac arrest which may result from the performance of any procedure(s), and in some cases, may lead to partial or permanent disability or death. Additional risks may include, but not limited to bleeding, infection, increased pain, headache, damage to nerves, seizures, stroke, paralysis, arachnoiditis, other organ system complications, other unforeseen circumstance, or even death.
    3.Specific risks pertaining to each specific procedure are as follows, but not limited to:

Epidural, Facet, Joint, Medial Branch Nerve, Sacroiliac Joint, Selective Nerve Root or Lumbar Sympathetic Injection/Block/Ablation: Low blood pressure, temporary weakness/numbness arm or leg, headache requiring epidural blood patch, meningitis, infection, paralysis.

Epidural or Spinal Opioid Injection: Itching, nausea, urinary difficulty, slowed breathing.

Discogram, Intradiscal Steroid Injection or IntraDiscal Electro Thermal Therapy (IDET): Infection or discitis, nerve injury, leg weakness, leg pain, paralysis.

Stellate Ganglion Block/Ablation: Hoarseness, difficulty swallowing, seizure, weak and/or numb arm, air in lung requiring a surgical chest tube, Infection.

Trigger point injection, Peripheral Nerve-Neuroma Block, Occipital Nerve Block, Intercostal Nerve Block/Ablation: Air in lung requiring chest tube in hospital, local pain from tissue and/or nerve irritation, dimpling of/depression in skin, pneumonia, chronic pain.

Celiac or Superior Hypogastric Plexus Block/Ablation: Low blood pressure, internal vessel/organ puncture requiring emergency surgical treatment to repair it, temporary or permanent bowel, bladder, or sexual dysfunction

Spinal Cord Stimulator implant/explant: Infection requiring hospitalization and removal of stimulator, meningitis, nerve damage.

Intra-articular Injection: Nerve damage, infection, loss of motion, avascular necrosis

    4.Possible side effects of the medication, agents, and procedures may include, but are not limited to the following: headache, flushing, low grade fever, temporary decrease in blood pressure, dizziness, fainting, anxiety, mood swings, insomnia, confusion, euphoria, blurred vision, tremor, tingling, numbness, weakness, difficulty urinating or defecating, incontinence, drowsiness, ringing in the ears, elevated blood sugar, elevated blood pressure (more common in patients with diabetes or hypertension), nausea, vomiting, rash, itching, swelling, abdominal pain, worsening of reflux and stomach ulcers, worsening of Crohn’s disease and ulcerative colitis, worsening of osteoporosis,, worsening of congestive heart failure, menstrual irregularities, transient worsening of depression, loss of skin pigment and atrophy at needle insertion site, infection or worsening of preexisting infection, worsening of kidney function in those with kidney problems such as renal insufficiency, loss of coordination, strength, sensation and mobility which would interfere with self-care (which would be detrimental to walking, driving, etc.), which would require you to arrange for assistance as needed. If you need assistance, it is your responsibility to arrange it, and you should not drive until you are fully independent. If any of the above mentioned side effects occur, they are usually temporary or short-lived, but may be persistent. Patients may also experience a temporary increase in pain or discomfort which may be from either the needle stick itself, or from the injected medication or contrast. This often resolves in 1-5 days, but may persist. A small minority of patients (even without the recognized complications discussed) may perceive increased pain that persists without a good explanation or reason. This is more likely (but still uncommon) to occur in persons with chronic pain before the injection.

    5.That no guarantee has been made to me as to result or cure or pain relief.

    6.Medically acceptable alternative / therapies and the benefits, risks, and complications of those alternatives or therapies.

    7.That I have the right to refuse the recommended procedure(s), the options available to me if I refuse to consent, and the expected consequences of such a refusal.

    8.The risk and benefits of not having the procedure/treatment done.

-I disclosed my health history accurately on the New Patient history form while also providing any changes or updates to my health history with my provider during subsequent follow up office visits. I consent to sharing this information with the health care facility where the injection will be done, my referring doctor, and insurers for the purposes of payment. I agree to the sharing of information I voluntarily disclose on diseases including but not limited to HIV, AIDS, hepatitis, and my history of drug, alcohol or substance abuse if any.

-In the event of accidental exposure of my blood or body fluids to physician or staff, I consent to oral / blood testing for HIV and hepatitis B / C.

-(Female Patients Only) I am not pregnant. I understand that there is a risk to the fetus if I undergo the injection and with the use of fluoroscopy if I do not know I am pregnant. If I am unsure about possible pregnancy, I will see a doctor to confirm that I am not pregnant before proceeding. I will let Southern Grace Pain & Regenerative Medicine know immediately if I am pregnant or think I may be pregnant prior to any treatment or procedure.

-I agree to notify my physician immediately if I am taking a blood thinner such as, but not limited to, Coumadin/Warfarin, Plavix, Xarelto, Aggrenox, Lovenox, Heparin, Aspirin, or other blood thinning medications. If I am on these or other blood thinning medications, I may need clearance to stop these types of medicine from my primary care doctor or prescribing physicians for these medicines, and stopping them does increase the risk to my overall health and well-being which was explained to me by the doctor providing clearance. By not stopping these blood thinning medicines, there is an increased risk of bleeding and more severe complications and certain procedures may not be performed by the physician upon their discretion.

-I have received and reviewed the pre-procedure instruction sheet. It was thoroughly explained to me and I agree to follow all instructions. I will immediately alert the office at Southern Grace Pain & Regenerative Medicine prior to the procedure if my health status changes or there are any changes in my prescribed medication from any physician. -I, being of sound mind, consent to the procedure and acknowledge all statements above. I agree that this consent form shall be valid for any date this procedure is scheduled