Pain Doctors NY Informed Consent Patient Form

    Name: Email (if you require a copy):

    I, have been advised and it has been recommended by my physician, 814 UNDERCLIFF MEDICAL for me to receive the treatment stated below. In signing this form and based on the information that has been provided to me, I am consenting to and authorizing the procedures listed below, use of medications necessary to complete the treatment and such other treatment as may be related to and necessary for my physician to complete this treatment.

    I also understand that in some instances it may be necessary and I am consenting to a series of treatments. I also agree that in addition to the information contained in this consent, I have been provided with an opportunity to discuss this treatment with my physician and his/her staff.

    Procedure(s): please include the procedure scheduled for you.

    Benefits and Risks

    These therapies are a medically recognized set of procedures that are frequently utilized for conditions involving musculoskeletal injuries, pain and discomfort. In almost all cases, this treatment is considered safe, minimally invasive with minimal risk of complications, and is done by a physician. I also understand that this treatment may altered decrease my pain complaints, but the treatment is not a guarantee from my physician that my pain will be completely eliminated.

    In signing this form, I am agreeing that my physician has reviewed with me and I understand that possible alternatives to this therapy are: 1. Refuse treatment at this time 2. Surgical intervention 3. Continued manual therapy or physical therapy 4. Medication Management 5. Alternative treatments 6. Absence of treatment

    The general risks for these procedures may involve:

    1. Allergic Reactions 2. Pain at the injection site 3. Infection at the injection site 4. Pneumothorax (punctured lung) during injections around the rib cage 5. Temporary numbness or dizziness 6. Increase in pain 7. Temporary or permanent nerve Damage or Paralysis 8. Spinal puncture.

    Your signature below indicates that:

    1. You understand the information provided to you on this form and agree to the procedure. 2. Your physician has adequately explained the procedure to you
    3. You have received all the information and explanation concerning the procedure and including aftercare have had your questions answered.
    4. You authorize and consent to the performance of the procedure.



    Patient Signature or authority (please sign and click submit)