Prolotherapy Consent Form

I, ______________________________________________, have read the patient information sheet regarding prolotherapy. I understand that this procedure is not guaranteed to relieve my pain, partially or totally. I also understand that there are potential complications which include increased pain, permanent numbness, infection, abscess, weakness, spinal headache, pneumothorax (collapse of the lung which may require hospitalization), allergic reactions, dizziness and nausea, and other disability.

I understand that this therapy is not covered by the provincial health insurance plan and that other extended health insurance companies may or may not cover this service. I agree to be responsible for my bill.

I give my permission for Dr. Garrett G. Swetlikoff, N.D. to use this treatment on me.

_____________________________________
Signed

_____________________________________
Date

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