A. The nature and extent of the procedure to be performed. (Initial) B. The most frequently occurring risks of the procedure involved and those risks which are unlikely to occur but which may involve serious consequences. These risks include but are not necessarily limited to the following: bruising, infection at site, injection into a vein or artery, introduction of infection into joint space, trauma to articular cartilage, injury to nearby nerves, and reactions to skin cleanser. (Initial) C. I acknowledge that there may be a period of time after the procedure when my body is reacting to this treatment with signs of new inflammation which include fever, malaise, and injection-site pain, swelling, warmth, or redness. I am aware if I develop any of these symptoms I should seek treatment in an Emergency Room, Urgent Care Center, or by my primary-care physician. I understand that Arctic Medical Center or its staff/subcontractors/practitioners/owners/employees will not be responsible to pay for, or manage any subsequent medical care related to a complication of my treatment since complications are a possible outcome of any medical or surgical treatment. (Initial) D. I understand that this procedure is “elective” and is possibly not covered by my insurance. (Initial) E. General risks, which may include pain, scarring, bleeding and infection. Furthermore, I acknowledge the risk of infection is an unavoidable and inherent risk of this procedure and also a risk of products, materials, and tissues supplied by outside vendors/third parties (Initial) F. The estimated period of incapacity or convalescence, if any. (Initial) G. The risks and benefits of this procedure and of any reasonable alternatives to this procedure, including having no treatment at all.(Initial) H. The likelihood of success of the procedure. (Initial) I. The likelihood of serious complications related to the procedure. (Initial) J. I was given the opportunity to ask any questions I have regarding the procedure and I have had those questions answered to my satisfaction. (Initial) K. I understand that I may consult or could have consulted with another physician about this procedure. (Initial) L. I understand that I have the right to refuse any medical/surgical treatment recommended at any time prior to its performance, and I have voluntarily chosen to go forward with receiving this treatment and procedure. (Initial) M. I authorize my practitioner to perform such additional procedures which her judgement is incidentally necessary or appropriate to help diagnose me or to help carry out my treatment. (Initial) N. If any foreseen condition arises during this procedure which requires transportation to a hospital, additional procedures, operation or medication including anesthesia and blood transfusions, I further request and authorize the practitioner to do whatever she deems advisable on my behalf. (Initial) O. I am aware that the practice of medicine and the administration of PRP is not an exact science, and I acknowledge that no guarantees have been made to me concerning the results or effectiveness of this procedure. Furthermore, there have been no guarantees or representations about the procedure. (Initial) P. I authorize that the practitioner may participate in my care; a representative or technician from a medical device company may be present at the procedure; medical photography may be utilized for medical, scientific, or educational purposes, provided my identity is not revealed in the photo or text. (Initial) Q. I acknowledge that I have read (*or had read to me) and fully understand the above information. Furthermore, I certify that all my questions and concerns regarding the procedure, its attendant risks, benefits, and alternatives have been explained to my satisfaction. I hereby authorize Erika Dominik APRN to perform the above-discussed procedure. (Initial)
I verify that I have explained the information contained in this document to the patient or person giving consent. It is my opinion that the person granting consent has fully understood all the subjects discussed.