You have both the right and responsibility to make decisions concerning your healthcare. The physician shall provide you with the necessary information but as a member of the healthcare team it is essential that you enter into the decision-making process. This form has been designed to document your informed consent to the procedure(s) that you have discussed with your physician.

1.  I authorize my physician to administer local anesthesia. I authorize the physician and/or associate to perform such extension of theprocedure(s) described above that they exercise their professional judgment determined to be necessary in the event other conditions become apparent during anesthesia, sedation or during the procedure(s) specifically authorized above.This authority includes treating conditions whether or not they were previously known or foreseen.     
2. In discussion with the above named physician and/or associate I have been informed  and understand:
   1. the benefits, risks and complications of this specific procedure(s).  
   2. that there are significant risks such as severe loss of blood, infection,    perforation/tear and cardiac arrest which may result from the performance of anyprocedure(s)and in some cases may lead to partial or permanent disability or death. Additional risks may include but are not limited to bleeding, infection,increased pain, headache, damage to nerves, seizures, stroke, paralysis, arachnoiditis,other organ system complications, other unforeseen circumstances or even death.  Specific risks pertaining to each specific procedure areas follows but not limited to:
      1. Epidural, Facet, Joint,Medial Branch Nerve, SacroiliacJoint, Selective Nerve Rootor Lumbar Sympathetic Injection/Block/Ablation: Low blood pressure, temporary weakness/numbness arm or leg, headache or requiring epidural blood.
      2. Patch, meningitis, infection, paralysis, death.
      3. Epidural or Spinal Opioid Injection: Itching, nausea, urinary difficulty,slowed breathing.
      4. Discogram, Intradiscal Steroid Injection or IntraDiscal Electrothermal Therapy(IDET): Infection or discitis,nerve injury, leg weakness, leg pain, paralysis.
      5. Stellate Ganglion Block/Ablation: Hoarseness, difficulty swallowing, seizures,weakand/or numb arm, air in lung requiring a surgical chest tube, Infection.  
      6. Trigger Point Injection,Peripheral Nerve-Neuroma Block,Occipital Nerve Block, Intercostal NerveBlock/Ablation: Air in lung requiring chest tube in hospital, local pain from tissue and/or nerve irritation, dimpling of/depression in skin, pneumonia, chronic pain.
      7. Celiac or Superior Hypogastric Plexus Block/Ablation: Low blood    pressure, internal vessel/organ puncture requiring  emergency surgical treatment to repair it, temporary or permanent bowel, bladder,or sexual dysfunction.  
      8. Spinal Cord Stimulator implant/explant,Spinal Infusion Pump implantor explant or Refill ,Epidural or Spinal Catheter implantation or explantation: Infection requiring hospitalization and removal of stimulator, catheteror pump, meningitis, nerve damage.  
      9. Myobloc/Botox (BotulinumToxin) Injections: Nerve or tissue damage, prolonged neuromuscular weakness.  
      10. Intra-articular Injection: Nerve damage, infection, loss of  motion avascular necrosis. 
   3. Possible side effects of the medication, agents, and procedures may include, but are not limited to the following: headache, flushing, lowgrade fever, temporary decrease in blood pressure, dizziness, fainting, anxiety,mood swings, insomnia, confusion, euphoria, blurred vision, tremor, tingling, numbness, weakness, difficulty urinating or defecating, incontinence, drowsiness, ringing in the ears, elevated blood sugar, elevated blood pressure (more common in patients with diabetes or hypertension), nausea, vomiting, rash, itching, swelling, abdominal pain,worsening of reflux and stomach ulcers,worsening of Crohn’s disease and ulcerative colitis, worsening of osteoporosis, worsening of congestive heart failure,menstrual irregularities, transient worsening of depression, lossof skin pigment and atrophy at needle insertion site, infection or worsening of preexisting infection,worsening of kidney function in those with kidney problems such as renal insufficiency, loss of coordination, strength, sensation and mobility which would interfere with self-care (which would be detrimental to walking, driving, etc.),which would require you to arrange for assistance as needed. If you need assistance, it is your responsibility to arrange it,and you should not drive until you are fully independent. If any of the above mentioned side effects occur, they are usually temporary or short-lived, but may be persistent. Patients may also experience a temporary increasein pain or discomfort which may be from either the needle stick itself, or from the injected medication or contrast. This often resolves in1-5days,but may persist.  A small minority of patients (even without the recognized complications discussed) may perceive increased pain that persists without a good explanation or reason. This is more likely (but still uncommon) to occur in persons with chronic pain before the injection.  
   4. that no guarantee has been made to me as to result or cure or pain relief. 
   5. medically acceptable alternative / therapies and the benefits, risks, and  complications of those alternatives or therapies. 
   6. that I have the right to refuse the recommended procedure(s), the options availabletomeif I refuse to consent, and the expected consequences of such a refusal. 
   7. the risks and benefits of not having the procedure/treatment done.
3. If necessary, Anesthesia care (Conscious IV Sedation) for this surgical procedure will be provided by a team consisting of Physician Anesthesiologists, Certified Registered Nurse. Anesthetic plan may include IV conscious sedation.  
4. I disclosed my health history accurately on the New  Patient history form while  also providing any changes or updates tomy health history withmy provider during subsequent follow up office visits. I consent to sharing this information with the health care facility where the injection will be done,my referring doctor, and insurers for the purposes of payment. I agree to the sharing of information I voluntarily disclose on diseases including but not limited to HIV, AIDS, hepatitis, and my history of drugs, alcohol or substance abuse if any​.  
5. In the event of accidental exposure of my blood or body fluids to physician o rstaff, I consent to oral / blood testing for HIV and hepatitis B / C.   
6. (FemalePatientsOnly) I am not pregnant.  I understand that there is a risk to the fetus if I undergo the injection and with the use of fluoroscopy if I do not know if I am pregnant. If I am unsure about possible pregnancy, Iwill see a doctor to confirm that I am not pregnant before proceeding.  I will let Bermuda Pain Services know immediately if I am pregnant or think I may be pregnant prior to any treatment or procedure.  
7. I agree to notify my physician immediately if I am taking a blood thinner such as,but not limited to, Coumadin/Warfarin, Plavix, Xarelto, Aggrenox, Lovenox,Heparin, Aspirin,or other blood thinning medications. If   I am on these or other blood thinning medications, I may need clearance to stop these types of medicine from my primary care doctor or prescribing physicians for these medicines, and stopping them does increase the risk to    my overall health and well being which was explained to me by the doctor providing  clearance .By not stopping these blood thinning medicines, there is an increased risk of bleeding and more severe complications and certain procedures may not be performed by the physician upon their discretion.  
8. I have received and reviewed the pre-procedure instruction sheet. It was thoroughly explained to me and I agree to follow all instructions. I will immediately alert the office of Bermuda Pain Services prior to the procedure if my health status changes or if there are any changes in my prescribed medication from any physician.
9. I,being of sound mind, consent to the procedure and acknowledge all statements above. I agree that this consent form shall be valid for any date this procedure is scheduled.   

 I have read and fully understand this form and understand that I should not sign this form if all items, including my questions have not been answered to my satisfaction or I do not understand any of the terms or words contained in this consent form.  

IF YOU HAVE ANY QUESTIONS AS TO THE RISKS OR HAZARDS OF THE PROPOSED  PROCEDURE OR TREATMENT, OR QUESTIONS CONCERNING THE PROPOSED PROCEDURE OR TREATMENT, ASK YOUR PROVIDER NOW, BEFORE SIGNING THIS FORM.  DO NOT SIGN THIS FORM UNLESS YOU HAVE READ AND THOROUGHLY UNDERSTAND THIS FORM. 

PROVIDER DECLARATION: Ihave explained the contents of the document to the patient and have answered all the patient’s questions. To the best of my knowledge, I feel the patient has been adequately informed and has consented.

Physician's Signature Dr. Annie Pinto M.D.

• Please wear comfortable, loose fitting clothing and shoes that are easy to take off/put on the day you come in for your procedure

• Take your routine medications before the procedure as usual (such as high blood pressure and diabetes medications) unless otherwise instructed and please bring them with you to the office

• If you are taking Coumadin/Warfarin, Heparin or Lovenox/Enoxaparin, Plavix/Clopidogrel, Ticlid/Ticlopidine or Pletal/Cilostazol or any other blood thinner, you must notify our office so that the timing of stopping and resuming these medicines can be explained.  If you are taking Coumadin/Warfarin you will need an INR (blood coagulation test); if not normal, the procedure could be canceled due to risk of bleeding.

• If you are on antibiotics, please notify our office, we may postpone the procedure until you have finished the medicine.  Cortisone inhabits the body’s response to fight infection.  Cortisone injections should not be given if there is an active infection elsewhere in your body.  If you have fever, chills, have a cold of flu or any infection, you should call our office as we may need to postpone the procedure;
  You are permitted to eat a light meal 2 hours before procedures, unless otherwise instructed.

• Please stay hydrated and drink plenty of water before and after your procedure.

• If you are a woman of childbearing age and you know or suspect that you may be pregnant, please inform the doctor immediately.

• If you have a known allergy; rash, hives or anaphylaxis to latex or any other medications please notify the office immediately

• You may need to arrange to have a driver available to collect you following the procedure as YOU WILL NOT BE PERMITTED TO DRIVE. This depends on the kind of procedure you are having and you can call the office to see if this is applicable to you

• Plan to be off work for the rest of the day after the procedure.  You may return to your current level of activities the next day, including return to work

• If you have any questions or concerns, please do not hesitate to contact our office prior to the procedure. You may call or email the office at 232-6824 or email info@pain.bm.

IF YOU NEED TO CANCEL THE PROCEDURE, 

PLEASE CONTACT OUR OFFICE AT 232-6824 AT LEAST 5 DAYS BEFORE YOUR SCHEDULED DATE