Consent Form for Care
I agree to be evaluated and treated at AZTMJ, PLLC, (herein after referred to as The Practice) by Dr. Stan Farrell as deemed medically appropriate. I acknowledge that no procedure will be performed without having been provided appropriate information regarding treatment and possible side effects or consequences. Signing this document implies informed consent on the part of the patient. In this arena, the Practice is released from harm. Although the physician and staff will make efforts to obtain my appropriate medical history and information, the Practice shall not be held responsible for issues of omission or negligence on the part of the patient.
I further acknowledge that the Practice is not functioning as my primary care/family physician, and if there are issues dealing with my primary care or internal medicine, they may be referred to my primary care physician by the Practice. There may also be instances where the Physician of the Practice will refer me to additional specialty care and evaluation as needed.
As for my responsibility to the Practice, I agree to attend appointments and therapies as scheduled. Multiple missed appointments, or inappropriate behavior may result in termination of services and referral to their physicians. Failure to cancel or no show for appointments will be subject to a charge for that visit.
During your therapy, it may become necessary to discuss surgical treatment options if painful or restrictive joint function continues. This may include arthroscopic or open TMJ surgery and/or possible jaw repositioning surgery. Dr. Farrell will, if necessary, discuss these options thoroughly. Following initial appliance therapy, there may be decisions to make by the patient and doctor concerning stabilizing or correcting the bite at the natural jaw position, determined by your muscles, if necessary. As joints and muscles relax and heal, there will be changes in your bite (how your teeth come together). Once, it is felt that you have reached your optimum level of improvement, adjusting your bite to your new jaw position may be recommended.
As part of your care, you may receive injections of one kind or another. Usually, these are trigger point injections into the motor point of various painful muscles. On occasion, a joint injection or Synvisc/Hyalgan injection will be done. This consent for treatment acknowledges that there can be side effects from any injection. Side effects can include: allergic reactions, localized pain at the injection site or pain along the referral pattern of the nerve or muscle injected. On rare occasions more serious adverse events have been known to occur: fever, infection, muscle and bone atrophy, rash anaphylaxis, pneumothorax, breathing difficulty, sudden changes in blood pressure, convulsions, death.
If a procedure is going to be done, a further discussion will ensue, but you are encouraged to ask questions. We wish to empower you to seek a higher level of health by getting involved. Help us to understand you.
Headace TMJ Disorders,sleep Apnea are chronic conditions that are managed,not cured we are not able to guarantee that all patient's condition will improve Upon rare occasion,condition and symptoms may worsen
No Intra-Oral Exam Performed We will not be examining your teeth or oral cavity, even though we will be looking in your mouth for other issues. Additionally, we will not be taking x-rays of your teeth. It is your responsibility to have a general dentist examine and maintain you oral health. If you do not have a general dentist we would be happy to recommend one.
Imaging (CT MRI) It may be required to have imaging of the head and neck performed for diagnostic and treatment purposes. Ultrasound and ICAT units are available on premises or a referral to an imaging center will be made.
Stark Policy/Notice Dr. Farrell may at times refer patients to Lab Express for lab work or to AZPMR for evaluation & treatment: both facilities are owned and operated by family members. Dr. Farrell does not have ownership, any financial interests nor does he receive any monetary compensation from either of the above entities.
Drug and Urine Screening At random times at the doctor's discretion our patients may be asked to provide a specimen for screening. This is intended to understand what chemical factors are contributing to your symptoms. An inquiry to the State Pharmacy Board may also be performed when indicated.