I request and authorize Dr. Bobby Nourani, and/or other doctors, assistants, students, and staff who may be assigned to my care, to perform the following procedure(s): INTERNAL MANIPULATION of the PELVIS, SACRUM, and or COCCYX. By signing below, I acknowledge:
1. that I have read this form,
2. that I understand the form and information provided by my doctor or doctor's designee,
3. that I have had the opportunity to ask questions and have had them answered to my satisfaction,
4. that I hereby give my authorization and consent to the performance of the procedure(s) listed above. The risks, and benefits of, and viable alternatives to the procedure(s) have been explained to me and I agree to proceed.
5. A physician has fully explained to me the nature and consequences of the procedure(s) needed to diagnose or treat my condition(s I have further had explained to me the discussed available alternative methods of treatment and possible outcomes. I have also been informed of the possible results of non-treatment. I understand the risk of complications, serious injury or even death that may result from both known and unknown causes. I have also been informed that there are other risks such as severe loss of blood, infection, cardiac arrest, etc., that can occur in the performance of any procedure.
6. I have also had it explained to me that before, during, or after the procedure listed above, I may develop or the physician may discover new conditions which the physician could not foresee. These new conditions might make it necessary or advisable for additional or different procedures to be used in my diagnosis or treatment. I therefore request and authorize my doctors to use such additional or different procedures as they think necessary or advisable for my diagnosis or treatment.
7. I also have been informed and I understand that the practice of medicine is not an exact science. No guarantees or promises have been made to me concerning the results of the procedure(s)
8. I consent to the observing, photographing, filming, televising, or recording of any of the procedure(s) to be performed for purposes of performance improvement, helping medical education or helping medical knowledge. I understand that my identity will not be made known by the pictures.
By signing this form I confirm I have read and understand all the material provided and I had all my questions answered.