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
Email address *
I authorize Hasib Sarij, MDand assistants or other personnel to perform:
Please select those that apply
Full Name *
Today's Date *
I authorize Integrated Spine & Pain Care to release medical records to my attorney as requested.
With (select one)
Clear selection
Print Name:
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
Clear selection
Never submit passwords through Google Forms.
This form was created inside of PatientPop. Report Abuse