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Pre-Procedure Form

Before a patient undergoes treatment for a Tarlov Cyst, they must sign a form signifying their understanding of the care they will be receiving and verifying they have had all the necessary evaluation procedures.  Please download the printable version of the form to sign.


 

This form verifies that you have had the proposed procedures to evaluate and treat your Tarlov Cyst explained and that you understand all aspects of that care.  We will schedule your care only after the form is signed.  Do not sign if you have any questions unanswered.  Please review your clinic notes as well to be sure they accurately reflect your complaints, and that you understand their content.

I have read the information on the topic of sacral and spinal cysts supplied to me by Dr. Long.

I have discussed the evaluation and management of my problem and the cyst(s) with Dr. Long.

My questions have been answered and I understand the procedures planned with their risks and complications of the proposed tests and treatments.  I understand the success/failure rates as currently known.  I understand aspiration is a new treatment and its outcome is still being evaluated.  Long term effects are unknown.

I also understand that I will have another opportunity to ask questions of the interventional radiologist when I give permission for the treatment of the cyst just before it is done.

I agree to the plan of evaluation and treatment and understand the time required to accomplish the goals of both.

I understand the post procedure care needed and my return to normal activities.

I also know I can refuse any of the proposed tests or treatments at anytime without affecting any other care by Dr. Long.

I also understand I can arrange a return clinic visit or a telephone call to review any aspects of care that are unclear by calling Dr. Long’s office for such an appointment.

 

I verify all of the above________________________________________

 

I have reviewed my clinic note(s) and agree it (they) accurately describe my complaints and that I understand the plan these note(s)contain._________________________________________