DISCLOSURE
The informed consent process should be considered an important conversation between you and the patient’s physician. The end of this form allows you to attest that all questions have been answered to your satisfaction and that you are giving informed consent. You are advised to read this form carefully and use this opportunity as an information seeking session.
If, after you have read and reviewed this form with the patient’s physician, you do not believe that you truly understand the risks, do not sign the form until all your questions have been answered.
PURPOSE
I understand the purpose of reduction of the displaced annular ligament of the radial head of the elbow (reduction of a nursemaid’s elbow) is to provide pain management and restore normal function and sensation of the arm.
IMPORTANT INFORMATION ABOUT THIS PROCEDURE
Most common complications include but are not limited to:
- Injury to the surrounding tissue including damage to bone, nerves and blood vessels.
- Recurrence of elbow dislocation requiring reduction in the future. (recurrence is 5-39% of children prior to 5yr of age).
- Patient discomfort during and after procedure
- Need for radiographs.
- Need for splint or a sling.
- Need for referral to an Orthopedist.
- Failure of the procedure.
PARENT OR LEGAL GUARDIAN’S CONSENT
I understand that some patients do not respond successfully to reduction of the displaced annular ligament of the radial head of the elbow. In some cases, there is the need for additional procedures, radiographs, immobilization of the arm and/or referral to a specialist (Orthopedist).
I understand that there are risks and complications associated with this procedure and that these risks and complications are rare as a result from displaced annular ligament of the radial head of the elbow. The most common complications include, but are not limited to: injury of the surrounding tissues (bone, nerves and blood vessels), discomfort during and after the procedure and recurrence of elbow dislocation.
I understand that no guarantee, warranty or assurance has been given to me that the proposed treatment will be successful. In most cases, the treatment should provide benefit in pain management and restoring sensation and function of the elbow and arm. Due to individual patient differences, certainty of success cannot be predicted. There is risk of failure and additional treatment despite the best possible care.
I understand that if complications occur, the patient may need to undergo additional medical procedures, radiographs and/or be referred to a specialist for additional treatment. I understand that in the course of this procedure it may become necessary to perform additional procedures which are not known to be needed at this time. I request that and hereby provide my informed consent to the physician to perform such procedures at his or her discretion if needed during the procedure.
I understand that my insurance company may not consider the procedure medically necessary, and as a result, refuse to pay the claim charges. If this occurs, I understand that I am required to pay, in full, the insurance company’s physician negotiated and contracted reimbursement discount amount.
I, consent, for the procedure above to be performed with my signature. I confirm that the provider has discussed the above information with me. I’ve had the opportunity to ask questions. All of my questions have been answered to my satisfaction and I do hereby agree and consent for the patient to undergo the procedure.