Interventional Procedures



I  voluntarily consent to the following procedure(s):

Doctor & Facility:  The procedure will be performed by my treating physician, W. Blane Richardson, MD, at Southern Grace Pain & Regenerative Medicine.
Basis of Consent: I give this voluntary consent to undergo the procedure noted above.  My treating physician has explained to me that this procedure is not medically necessary.  I have discussed with my treating physician my general medical conditions and allergies.  I have informed my treating physician about any medications (including prescriptions, over the counter, herbal remedies and supplements) that I am currently taking. My treating physician has fully explained the following:
  • The purpose and nature of the procedure to be performed.
  • The material risks of the procedure.
  • The benefits of the procedure.
  • The possibility of complications during the procedure.
  • The alternative treatments and procedures available.
  • The consequences of refusing the procedure.
I know that I may make requests for additional information about any of the above issues prior to the commencement of the procedure. I also know medicine and surgery are not exact sciences and that no guarantees can be made concerning the results of the procedure.

Consent for Additional Procedures:  I also give voluntary consent for any necessary routine diagnostic procedures and medical treatment performed by my treating physician as part of the above medical procedure.  I also consent to the performance of other unforeseen operations or procedures if my treating physician determines they are required.  Such a situation may arise, for example, if the procedure discussed above discloses a previously unknown condition and my treating physician determines, based on medical judgement, the unforeseen procedure is reasonably necessary to improve or maintain my health.  I also understand other necessary medical professionals, designated by my treating physician, may also participate in my procedure.

Educational Use Authority:  I give permission for medical data concerning my procedure and subsequent treatment to be used in clinical teaching by the treating physician and others participating in my procedure and give permission to the photographing, videotaping or televising of my procedure for teaching purposes, provided my identity is not revealed by the pictures or descriptive text accompanying them.

Observers in the Procedure Room:  For the purpose of advancing medical education, I consent to the admittance of observers approved by the Facility Director in the procedure room.  Under the supervision of my treating physician, I authorize clinical coaching of personnel in relation to my patient care.

Lab Services:  My treating physician may send specimens to a professional pathology laboratory for a pathological diagnosis.  Pathology services are billed separately by those individual physician and laboratories.

Disposal of Medical Tissue:  I consent to the disposal of any tissue removed during the procedure in accordance with customary practices.

Transporting and Care after the Procedure:  I understand that it is my responsibility and I have arranged for a responsible adult to drive me home and provide assistance following my procedure.  I acknowledge that I have been advised not to drive until the effects of any medications have worn off.  I understand this to mean that I should no drive until the day after my procedure or as directed by my treating physician.

Additional Testing of Blood: In the event someone associated with my procedure becomes accidently exposed to my blood or bodily fluids, such as in the case of an accidental needle stick or direct contact with the skin or mucous membrane with my blood or bodily fluid, I consent to the testing of my blood for blood born pathogens, including HIV and Hepatitis.

Personal Effects:  I release the staff and facility at Southern Grace Pain & Regenerative Medicine from any responsibility for loss or damage to money, jewelry or other personal effects that I bring into the facility.

I certify that I have read and fully understand the above information, the procedure has been fully explained by my treating physician and I authorize and consent to the performance of the procedure
Patient Address

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