INFORMED CONSENT FOR RISKS AND MEDICAL NECESSITY OF INVASIVE PROCEDURES
I understand that there are risks associated with invasive pain management. These risks include but are not limited to
the following:
Risks of Injection:
1. nerve injury.
2. spinal cord injury
3. brain injury (stroke)
4. paralysis
5. muscle injury
6. joint injury
7. infection
8. bleeding
9. pneumothorax (collapsed lung)
10. increased pain
11. death
Risks of steroid:
1. insomnia
2. increased appetite.
3. weight gain.
4. fluid retention
5. changes in body shape.
6. muscle atrophy
7. mood changes
8. adrenal suppression (shutting down of body's own steroid production)
9. skin changes.
10. osteoporosis
11. vertebral body compression fracture.
12. avascular necrosis of the hip (chronic hip fracture)
13. bleeding stomach ulcers
14. cataracts
I understand that my injection could cause short-term weakness, and/or numbness in my arms or legs, as well as
balancing difficulties and visual disturbances. If any of these symptoms occur after my injection, I agree not to drive. I
agree that I will wait in the clinic until my symptoms subside, I will find alternative transportation home, or I will be
transported to another medical facility for ongoing management.
MEDICAL NECESSITY FOR INVASIVE PAIN MANAGEMENT
I have consented to undergo an invasive procedure for the purpose of pain management. I understand that there are
potential risks and potential benefits of this procedure. I certify that this procedure is medically necessary for the
following reasons:
□ My pain is severe for significant periods of time.
□ My pain is interfering with my ability to function and to perform activities of daily living.
□ My pain has not completely responded to more conservative non-invasive management.
The risks and issues with invasive pain procedures have been explained to me to my satisfaction and my questions have
been answered.
PATIENT SIGNATURE:__________________________________________
Consent for Interventional Pain Management Procedure
Procedure: ____________________________________________________________________________
You are about to undergo an invasive procedure for the purpose of diagnosis and/or treatment of persistent
pain. The procedure we are recommending requires placement of needles into the body and injections of
medicines, anesthetics and/or chemicals into the body. In addition, if you are undergoing a nerve
destruction procedure such as radio frequency nerve ablation or chemical neuroablation, nerve-destroying
heat current and/or nerve-destroying chemicals may be delivered to your body. We believe that the
procedure you are about to receive will help you to become more pain free. However, there is no guarantee
that the procedure will relieve your pain and there is a possibility that your pain may be the same or worse
afterward. Persistent pain is often very difficult to diagnose and treat, and we can only use our best
judgment and medical expertise to recommend and perform interventions that we hope will help you. As
with most interventions in medicine, there is considerable risk to invasive pain therapies. Risks include but
are not limited to the following: bleeding, infection, damage to nerves or spinal cord, damage to blood
vessels or other body tissues, toxic or allergic reactions to medications or chemicals injected, accidental
injection into the blood vessels or spinal fluid, paralysis and/or death.
Special Notes: _________________________________________________________________________
Please ask any questions you may have prior to signing this consent.
Patient Signature: _______________________________________________________________________
Physician Signature: _____________________________________________________________________
Witness: ______________________________________________________________________________
Date: _______________________
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I, _____________________________________, viewed the video “Risks Associated with Pain
Patient Name
Clinic Procedure” on ___________________.
Date
_________________________________________
Patient Signature
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According to records, patient viewed the video “Risks Associated with Pain Clinic Procedure” on
_______________________
_________________________________________
Date
Staff Signature
CONSENT FOR MEDICATION USE
At MAPS we may be using specially prepared medications obtained from a custom
compounding pharmacy to inject into your spine or other parts of your body or placed in
your pump for continuous delivery. These medications are prepared to our specifications
without preservatives using standard compounding techniques. The medications we
obtain from the compounding pharmacy are all commonly used for spinal injections and
pump fills and are sometimes purchased from a manufacturing pharmacy. Due to a
recent national shortage of these medications, we have had difficulty obtaining our usual
spinal medications from the manufacturing pharmacies. We have therefore decided to
obtain the medications from a compounding pharmacy. The compounding pharmacy is
different from the manufacturing pharmacy in that the Food and Drug Administration
(FDA) does not monitor and does not regulate the compounding pharmacies. The FDA
does monitor and regulate the manufacturing pharmacies. Nonetheless, we have every
confidence in the safety and efficacy of the compounded medications. Please sign this
consent confirming that you understand that some or all of the medications injected into
your body may have been created by a compounding pharmacist without FDA regulation.
If you have any questions regarding compounding medications, please ask the doctor or
nurse to explain further. Thank you.
______________________________
Patient Signature
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Date
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Witness Signature
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Date