Healthcare Headache Consent Form

Healthcare Headache Consent Form

Patient Information

Patient Name:    Date of Birth:

Gender:    Emergency Contact:    Phone:

Insurance Information

Medical History

Please indicate if any apply:
Pregnant or currently trying to conceive    Taking blood thinners / anticoagulants    Bleeding disorder
Implanted electronic device (e.g., pacemaker)    Chronic opioid or controlled substance use

Proposed Treatment for Headache

The clinician has recommended one or more of the following interventions for the diagnosis or treatment of headaches. Please mark all that apply.

Occipital nerve block / diagnostic block
Trigger point injection
Sphenopalatine ganglion block
OnabotulinumtoxinA (Botox) injections for chronic migraine
Medication infusion or intravenous therapy
Other (specify):

Risks, Benefits, and Alternatives

I understand that the proposed treatment is intended to diagnose or reduce headache pain and frequency. Common benefits include reduction in pain intensity and frequency and improved function. Alternative options include medication management, physical therapy, psychological therapies, lifestyle modification, and referral to other specialists. I understand that no specific outcome can be guaranteed.

I acknowledge that risks, which may be immediate or delayed, include but are not limited to: localized pain at the injection site, bleeding, infection, bruising, temporary numbness or weakness, allergic reaction, increased headache, transient visual disturbance, nerve irritation or injury, vascular injury, worsening of symptoms, hospitalization, and in rare cases stroke or death. Specific risks related to Botulinum toxin include ptosis, swallowing difficulty, flu-like symptoms, and spread of toxin effect.

I have had the opportunity to ask questions about the nature of the treatment, risks, likely benefits, and alternatives. My questions have been answered to my satisfaction. Initials acknowledging review:

Anesthesia / Sedation / Medication

If local anesthetic, sedation, or intravenous medications are used, I consent to their use and acknowledge that these carry additional risks including respiratory depression, allergic reaction, cardiovascular complications, and need for emergency interventions. I understand I must follow pre-procedure instructions regarding fasting and medication adjustments (e.g., anticoagulant management) as directed by the clinician.

Post-Procedure Care and Instructions

I acknowledge I will receive post-treatment instructions and agree to follow them. I understand to seek immediate medical attention or contact the clinic if I experience signs of infection, uncontrolled bleeding, severe swelling, progressive weakness, breathing difficulty, or other concerning symptoms.

HIPAA Authorization and Release of Information

I authorize the release of my protected health information related to this treatment to my insurance company and to other healthcare providers for treatment and billing purposes. I understand that records may include clinical notes, procedure documentation, and images. This authorization is voluntary and may be revoked in writing at any time, except where action has already been taken in reliance on this authorization. Authorization expires on:

I consent to the taking of clinical photographs, video, or other imaging for documentation, treatment planning, or teaching purposes. I understand that identifying information will be protected and images used only as described unless I indicate otherwise. Consent to images: Yes

Consent and Certification

By signing below I certify that I am the patient or the legal guardian or authorized representative of the patient and that I have the authority to consent to the proposed treatment. I certify that the information I have provided is accurate and complete to the best of my knowledge. I authorize the clinician to perform the procedures described above and such additional procedures as may be necessary in the clinician's professional judgment in the event of unforeseen circumstances.

I understand I may withdraw or revoke this consent at any time prior to the initiation of the treatment by informing the clinician, but that revocation will not apply to treatments already performed. I consent to emergency treatment if a serious adverse event occurs during the procedure.

Consent for treatment: I consent
Authorization to bill insurance: I authorize billing and payment to be submitted to my insurer as necessary
Release of records: I authorize release of records to referring providers and payors

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