WILLIAM BLANE RICHARDSON, MD

| SOUTHERN GRACE PRECISION & AESTHETICS

WILLIAM BLANE RICHARDSON,MD

SOUTHERN GRACE PRECISION & AESTHETICS

LUMBAR DORSAL ROOT GANGLION PULSED AF ABLATION

SCHEDULE

YOUR CONSULTATION TODAY

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  • I, authorize Dr. Blane Richardson, to perform the following procedure: STERILE PLACEMENT OF HORMONE PELLETS UNDER THE SKIN.
  • I understand the reason for the procedure is hormone replacement therapy using Estradiol and/or Testosterone.
  • RISKS: Risks that may be associated with this particular procedure include bleeding, infection and/or pellet extrusion
  • LOCAL ANESTHESIA: The administration of anesthesia also involves risks; most importantly, a rare risk of reaction to medication causing death. I consent to the use of such anesthetics as may be considered necessary by the medical professional, physician or practitioner responsible for these services.
  • I understand that no guarantee or assurance has been made as to the results of the procedure and that it may not cure any condition I may have.

    PATIENT’S CONSENT: I have read and fully understand this consent form and understand I should not sign this form if all items, including my answers, have not been explained or answered to my satisfaction or if I do not understand any of the terms or words contained in this consent form.


  • Patient Address


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