No guarantee: I understand that no warranty or guarantee has been made to me as to the result of the medical treatment for services rendered to me or a cure of my medical condition.
Benefits: To have a decrease in pain.
Risks: Just as there may be risks and hazards and continuing the present condition without treatment, there are also risks and hazards related to the performance of surgical, medical and/or diagnostic procedures planned for me. I understand that common to surgical, medical and/or diagnostic procedures, there is the potential for infection, blood clots in the veins or/and lungs, hemorrhage, allergic reactions and even death. Additionally, risks may include nerve damage, paralysis and spinal headaches. These additional risks may require bedrest and/or a blood patch (s) in order to get relief.
Alternatives: Alternative is not to have the procedure done.
Photographs: Observers: I consent to the photographing and videotaping or one or the other or both to be performed into the presence of students or other observers present in the operating/procedure room to observe for the purpose of advancing medical education. I am aware that Dr. Molette has permission or my consent. Any videotaping/photography or other similar documentation, if used, would include appropriate portions of my body for medical, scientific, poor educational purposes. My identity would not be revealed by descriptive text accompanying the pictures.
I have been given an opportunity to ask questions about my conditions, alternative forms of treatment, risks, and benefits of the planned procedure(s) and the risk/consequences of nontreatment. All questions have been answered to my satisfaction. I have sufficient information to give this informed consent. I certify that this form has been fully explained to me. I have read this form or it has been read to me. The blank spaces have been filled in by me or my advocate (legal) and I understand its contents.