Authorization for Neurosurgical Treatment and Procedures

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record #: ______________ Date: _____________________

Authorization Statement

I, _________________________________, hereby authorize Dr. _________________________ and associates to perform the following neurosurgical procedure(s):

Acknowledgments and Consents

• I understand that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantees have been made to me concerning the results of the proposed treatment and/or surgical procedure(s).

• I consent to the administration of anesthesia by a qualified anesthesiologist/nurse anesthetist and to the use of such anesthetics as deemed necessary.

• I understand that during the course of the procedure, unforeseen conditions may arise that necessitate additional or different procedures than those explained. I authorize my surgeon and associates to perform such procedures as deemed necessary in their professional judgment.

Specific Risks and Complications

I understand that the following risks and complications may occur (but are not limited to):

1. Infection
2. Bleeding
3. Neurological deficits
4. CSF leak
5. Pain or discomfort
6. Need for additional surgery

Financial Authorization

I authorize the release of any medical information necessary to process insurance claims and request payment of benefits to the physicians or supplier for services described above.

Signatures

Patient/Legal Guardian: _________________________ Date: _________

Witness: _____________________________________ Date: _________

Physician: ____________________________________ Date: _________

Emergency Contact

Name: ______________________________________ Relationship: ________________________________ Phone: _____________________________________

This authorization is valid for 30 days from the date of signature.