My physician has informed me that this injection procedure, based on current medical evidence, is appropriate for my condition, though there can be no guarantee that the treatment will be effective or that my condition will improve. In addition, my physician has explained that there is a possibility that my condition could return. This procedure/treatment is not FDA approved.
BENEFITS AND ALTERNATIVES OF TREATMENT
My physician has fully explained to me the nature and the purpose of treatment. My physician has explained how this treatment may benefit me. My physician has also explained to me that there are other possible methods of treatment and explained what they are.
RISKS
My physician has explained that this treatment must be performed by a physician. My physician has told me that there are potential risks and complications, from both known and unknown causes, that could reasonably be possible. Included in our discussion were the following risks:
WITHDRAWAL OF CONSENT
I understand that I am free to withdraw this consent and to discontinue treatment at any time. NO GUARANTEES. I acknowledge that no guarantees or assurances have been made to me concerning this treatment.
FINANCIAL RESPONSIBILITY
I also acknowledge that I have been informed that my health insurance or other health care benefit plan will not cover the entirety of this treatment. Nonetheless, I wish to have the treatment, and understand that I may have to pay for this treatment myself. I understand that the Practice will not submit a claim and will not be responsible if the claim is denied.
UNDERSTANDING OF THIS FORM
I acknowledge that I have read this document in its entirety and that I fully understand it and that all blank spaces have been either completed or crossed off prior to my signing.