Charles Davies
 
 
 Neurological, Orthopedic & Spine Center 
 2016 December 15 
 Informed Consent 
 Date: 
 PatientName: Charles Davies 
 Telephone Number 111-111-1111 
 Saldyem Berti 
 I Authorize Dr.(s) 
 ("Physician"), and such assistants as may be selected 
 by him to perform the proposed surgery and /or procedure of 
 L4-5 interbody Iven c 44-5 
 bilut pedicle screws 
 And any other needed procedure 
 If any unforeseen conditions arise during the course of the procedure, I authorize and request the Physician 
 and his assistant to perform such additional procedures as they deem advisable, which may be in addition 
 to or different from those now planned.  
 This form did not imply a iscussion of payment or obligation to proceed with procedure. 
 Emergency Contact: 
 Patient/Legal Guardia signature nd Printed Na he 
 New 
 2014 October 11 
 Physicians Signature and printed Name 
 Date 
 Corner 
 2014 October 11 
 Witness Signature and printed Name 
 Date 
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