Pain Management Consent
Hasib Mikael Sarij, M.D.
1111 Broad Hollow Rd. (Route 110) Unit 114 Farmingdale, NY 11735
Tel: (516) 336-8659 • 631-270-7733 / Fax: (516) 584-0055
I authorize Hasib Sarij, MDand assistants or other personnel to perform:
Please select those that apply
Trigger Point Injection
Epidural Steroid Injection
Medial Branch Nerve Block
Right Brachial Plexus Block
Radio Frequency/Neuro Ablation
Lumbar Sympathetic Block
Selective Nerve Block
Major Joint Injection
Minor Joint Injection
Left Brachial Plexus Block
Peripheral Nerve Block
Right Sacro-Iliac Joint Injection
Left Sacro-Iliac Joint Injection
Right Intercostal Nerve Clock
Left Intercostal Nerve Clock
Right Stellate Ganglion Block
Left Stellate Ganglion Block
I authorize Integrated Spine & Pain Care to release medical records to my attorney as requested.
With (select one)
In addition, I understand the radio-opaque contrast may be injected to assist in determining correct needle placement. I understand the reason for this procedure is: pain relief. I understand that the alternatives to this procedure include: Medical therapy and/or surgery. I understand that I may have an intravenous catheter placed and receive IV sedation to relax me and make my procedure more comfortable. If I have IV sedation, I agree to have a responsible adult drive me home and assist me after my procedure, if necessary. I understand I cannot operate any motor vehicle or make any legal decisions for 12 hours after sedation as my ability to perform these tasks may be impaired.
I request IV sedation be given during my procedure
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