Amanda Leblanc

 
 21/01/25 08:25 
 1 12 >> unknown 
 P 23/13
 -2- 
 COASTAL PAIN & NEUROLOGY CENTER 
 I understand that medicine and surgery are not exact sciences.
 I have discussed the risks of not having this/these procedure(s) with my physician. 
 
 I understand and read the English language or have had adequate interpretation or 
 translation of this document. Any and all questions I have regarding this/these proposed 
 procedure(s) have been answered to my satisfaction. 
 ATTENTIONPATIENTS WITH "NO CODE" OR DO NOT RESUSCITATE STATUS: 
 I understand that do not resuscitate (DNR) and "No Code" status is void during this/these 
 procedure(s) and during the immediate post-operative period. Initials: 

 The patient is unable to sign or give consent as reflected in the medical records because: 
 Longhu 
 
 21/11/22
 Signature of Patient or Health Care Surrogate 
 Date 
 Time 
 Signature of Witness 
 Date 
 Time 
 I certify that I have informed the patient of the responsibility available alternatives to the 
 proposed surgical and/or invasive procedure(s), the inherent specific potential risks and 
 complications, benefits and alternatives of the procedure(s) and the results of the 
 procedure(s) which I consider likely to occur. 
 Signature of Provider 
 Date 
 Time
