Neurosurgical Treatment Agreement and Informed Consent

Patient Information

Name: _________________________ Date of Birth: _________________ Medical Record Number: _________ Date: _________________________

1. Procedure Information

I hereby authorize Dr. _________________ and associates to perform the following neurosurgical procedure:

2. Nature of Procedure

I understand that the procedure involves: [physician to detail specific procedure]

3. Risks and Complications

I acknowledge that I have been informed of the following potential risks and complications:

• Infection
• Bleeding
• Neurological deficits
• CSF leak
• Anesthesia-related complications
• Pain or discomfort
• Need for additional surgery
• In rare cases, permanent disability or death

4. Alternative Treatments

I understand that alternatives to this procedure include:

• Conservative management
• Medical therapy
• Alternative surgical approaches
• No treatment

5. Recovery Expectations

I understand that:

• Recovery time varies by individual and procedure
• Physical therapy may be required
• Follow-up appointments are mandatory
• Activity restrictions will apply

6. Financial Agreement

I understand that I am responsible for:

• Insurance copayments and deductibles
• Non-covered services
• Pre-authorization requirements

Signatures

Patient/Guardian: _________________________ Date: ________________ Witness: _________________________________ Date: ________________ Physician: _______________________________ Date: ________________

Contact Information

Emergency Contact: ______________________ Phone: ________________

This document is part of your permanent medical record