I hereby authorize the professional staff at OnCall Pain to administer treatment for the purpose of medical care as needed.
 
I have been informed of the nature and purpose of treatment, common side effects thereof, alternative treatment modalities, approximate length of care, and that consent can be revoked orally or in writing prior to or during the treatment period.
 
I have read and fully understand the above Authorization for Treatment. No guarantee or assurance has been made to me as to the results that may be obtained.
               
All healthcare providers are legally required to report incidences of communicable diseases to the Department of Public Health. If, during the course of treatment, it is determined by your healthcare provider that you have acquired a communicable disease, this information will be reported to the Department of Public Health. This report will be made to individuals who are required by law to be notified.

By typing your name and submitting this form, you acknowledge that you have reviewed, understand and accept ONCALL PAIN'S Informed Consent for Treatment.