Your signature on this document shall serve as verification that you have received that information and have given your consent to the procedure. You should therefore read this and any attached information carefully and ensure that all your concerns have been addressed by the consultant sufficiently before you give consent.
You understand if a chiropractor consulted with you regarding your neuromusculoskeletal condition, you are being referred to licensed medical professionals for allograft injections containing stem cells and the protocols will be up to their professional medical opinion.
Release of Liability: I release Joint Repair Clinic of MT and staff from liability associated with this procedure except for liability that may be imposed by the laws of the state of Montana.
Adverse reactions and possible side effects: It is possible for there to be unforeseen adverse reactions, side effects, and risks that are not included in this list. Some possible side effects can be: immediate pain at the injection site, stiffness is in the injected joint, bruising, allergic reaction (ex. to the sulfa in DMSO), infection, nerve or muscle injury, nausea/vomiting, dizziness or fainting, swelling after injections, bleeding, tendon rupture (if tendon inadvertently injected), depigmentation (whitening of skin). Thus, before undergoing one of these procedures, understanding the associated risk is essential. No procedure is risk-free. If any signs of a reaction happen, contact the medical provider immediately.
Referral for the following procedure has been recommended:
Structural Tissue Allograft Containing Human Umbilical Cord Tissue
Upon your authorization and consent, this Joint Injection will be performed on you by a Montana Licensed Medical Provider. All invasive procedures carry the risk of unsuccessful results, complication, injury, or even death from both known and unforeseen causes, and no warranty or guarantee is made as to results or cure. You have the right to be informed of the nature of the procedure and its actual or potential risks, benefits, and side effects, as well as any reasonable alternative(s) and the side effects of such alternative(s). You also have the right to give or refuse consent to any proposed procedure or therapy at any time prior to its performance.
Stem cells arrive frozen, and once received they must be injected that day. By signing below, you are acknowledging that there is no refund if you do not keep your appointment.
Therefore, as stated above, your signature on this form indicates that:
You have read and understand the information provided in this form and any attachment to this form.
The procedure has been adequately explained as set forth above, along with risks, benefits, and other information described on this
You have had the chance to ask any and all questions regarding this procedure.
You have received all of the information you desire concerning the procedure.
You authorize and consent to the performance of the procedure with complete understanding of it and its risks and benefits.