GENERAL CONSENT TO TREATMENT AND RIGHT TO REFUSE TREATMENT
When a drug or device is approved for medical use by the Food and Drug Administration (FDA), the manufacturer produces a “label” to explain its use. Once a device or medication is approved by the FDA, physicians may use it “off-label” for other purposes if they are well-informed about the product, base its use on firm scientific method and sound medical evidence, and maintain records of its use and effects. Many commonly used pain treatments fall into this category.
General Consent to Treatment: Having come to MARYLAND PAIN SPECIALISTS for evaluation and/or treatment, by signing below, I, (or my authorized representative on my behalf) authorize MARYLAND PAIN SPECIALISTS and their staff to conduct any diagnostic examinations, tests and procedures and to provide any medications, treatment or therapy necessary to effectively assess and maintain my health, and to assess, diagnose and treat my illness or injuries. I understand that these treatments may be “off-label.” It is the responsibility of my individual treating healthcare providers to explain to me the reasons for any particular examination, test or procedure, the available treatment options, common risks, anticipated burdens and benefits associated with these options as well as alternative courses of treatment. It is also my responsibility to ask questions about my treatment plan when I have them.
Right to Refuse Treatment: In giving my general consent to treatment, I understand that I retain the right to refuse any particular examination, test, procedure, treatment, therapy or medication (label and off label) recommended or deemed medically necessary by my individual treating health care providers.
I understand that the practice of medicine is not an exact science and that no guarantees have been made to me as to the results of my evaluation and/or treatment.
I have read and fully understand the General Consent described above. I further understand that my signature signifies that I accept the terms as set forth in this agreement.