PLACE LABEL HERE

PLACE LABEL HERE

SummitRidge

Form Name

(This form is designed to comply with the Georgia Informed Consent Law O.C.G.A. 31-9-6.1)

PATIENT NAME:______DATE: ______

TIME: ______

The diagnosis requiring this procedure is:Severe headache, fever or altered mental status______

The nature of the procedure is:Lumbar puncture (spinal tap). Insert a needle into the lower spinal canal to

remove spinal fluid for testing.

The purpose of this procedure is:___Rule out meningitis (infection of fluid around the brain) as a diagnosis

___Rule out subarachnoid hemorrhage (bleeding around the brain from

blood vessel rupture) as a diagnosis

This procedure involved the material risk of infection, allergic reaction, severe loss of blood, loss or loss of function of any limb
or organ, paralysis, paraplegia or quadriplegia, disfiguring scar, brain damage, cardiac arrest or death.

ADDITIONAL RISKS: In addition to the material risks listed above, there may be other potential risks involved in this procedure
including, but not limited, to the following: headache, pain, infection in spinal fluid, spinal fluid leak______

______

The likelihood of success of this procedure is: ( X) good( ) fair( ) poor

THE PRACTICAL ALTERNATIVES TO THIS PROCEDURE ARE: None______

If I choose not to have the above procedure, my prognosis (future medical condition) is: Guarded______

I understand that during the course of the procedure described above, it may be necessary or appropriate to perform additional
procedures which are unforeseen or not known to be needed at the time this consent is given. I consent to and authorize the persons
described herein to make the decisions concerning such procedures. I also consent to and authorize the performance of such
additional procedures as they deem necessary or appropriate.

I consent to diagnostic studies, tests, x-ray examinations and any other treatment or courses of treatment relating to the diagnosis or
procedures described herein.

I consent to the use of conscious or deep sedation, as planned by my treating physician. The risks, benefits and alternatives of such
sedation have been explained to me. I understand that specific risks of sedation include, but are not limited to, changes in blood
pressure, allergic reaction, difficulty breathing, cardiac or respiratory arrest, seizure, coma and death.

I consent that any tissues, specimens, organs or limbs removed from my body in the course of any procedure may be tested or retained
for scientific or teaching purposes and then disposed of within the discretion of the physician, facility or other health care provider.

I understand that the physician, medical personnel and other assistants will rely on statements about the patient, the patient’s medical
history, and other information in determining whether to perform the procedure or the course of treatment for the patient’s condition
and recommending the procedure which has been explained.

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I understand that the practice of medicine is not an exact science and that NO GUARANTEES OR ASSURANCES HAVE BEEN
MADE TO ME concerning the results of this procedure.

BY SIGNING THIS FORM, I ACKNOWLEDGE THAT I HAVE READ OR HAD THIS FORM READ AND/OR
EXPLAINED TO ME, THAT I FULLY UNDERSTAND ITS CONTENTS, AND THAT I HAVE BEEN GIVEN AMPLE
OPPORTUNITY TO ASK QUESTIONS AND THAT ANY QUESTIONS HAVE BEEN ANSWERED SATISFACTORILY.
ALL BLANKS OR STATEMENTS REQUIRING COMPLETION WERE FILLED IN AND ALL STATEMENTS I DO NOT
APPROVE OF WERE STRICKEN BEFORE I SIGNED THIS FORM. I ALSO HAVE RECEIVED ADDITIONAL
INFORMATION INCLUDING BUT NOT LIMITED TO THE MATERIALS LISTED BELOW RELATING TO THE
PROCEDURE DESCRIBED HEREIN.

I hereby voluntarily request and consent for Dr.______as my physician, and any other physician(s), and
such associates, assistants or other medical personnel involved in performing such procedure(s), to perform the procedure(s) described
or referred to herein. I further consent to the presence of device or supply manufacturer’s representatives in the operating room as
may be deemed appropriate by my physician.

Additional materials used, if any, during the informed consent process for this procedure include:

______

Signature of Person Giving Consent Relationship to patient if not the patient

Patient unable to sign because:

______

Responsible Practitioner’s Statement:

I have reviewed the contents of this form, including the risks, benefits and alternatives to the proposed procedure, with the patient or
the patient’s decision-maker, and have provided the patient/decision-maker with an opportunity to ask questions.

______

Responsible PractitionerDate/Time

FORM #2-14979 REV. 03/2006Page 1 of 2