I, the above mentioned patient hereby authorize the above-named physician and/or assistants or associates of their choice to perform the operation indicated above and/or such operations and/or any other therapeutic procedures upon me they may deem necessary or advisable. The necessity for the operation, the potential benefits, alternatives and the potential risks of the operation have been explained to me and no warranty or guarantee has been made as to the result or cure. I have been advised of the comparative risks, benefits and alternatives associated with performing the procedure in an office instead of a hospital.
I hereby authorize the above named physician and their associates or assistants to provide such additional services for me as he or they may deem necessary or advisable, including procedures different from those now contemplated and including but not limited to the administration and maintenance of anesthesia and the performance of services involving pathology and radiology, and I hereby consent thereto.
The risks of the procedure including potential problems that might occur during recuperation include but are not limited to increased pain, bleeding, infection, headache, nerve/spinal cord injury, and/or loss of sensory or motor function, seizure, death.
I/We authorize all doctors, pharmacists, hospitals, Pennsylvania Pain and Spine Institute or other institutions rendering care and treatments to furnish the responsible parties and/or insurance companies with full information regarding treatment rendered, (including copies of my records). A photo-static copy of this authorization shall be considered as effective and valid as the original.
The undersigned certifies that he/she has read the above and is the patient, parent, guardian or representative is authorized to execute the above and accept its terms and risks.