1. I authorize the performance upon _________ of the following procedure ______________ performed under the direction of ______(physician's name).
2. I consent to the administration of local anesthetics, narcotics, and/or other medications into the epidural space.
3. I understand that the following, among others, are possible complications or risks of the procedure and that while they are uncommon, they have been reported in the medical literature:
4. I consent to the performance of procedures in addition to or different from those now contemplated, whether or not arising from presently unforeseen conditions, which the above named doctor or his associates or assistants including residents, may consider necessary or advisable in the course of the procedure.
5. The nature and purpose of the procedure, possible alternative methods of treatments, the risks involved and the possibility of complications have been fully explained to me. I understand that no guarantee or assurance has been given by anyone as to the results that may be obtained.
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