I request that Dr. Andrew Kochan treat me with
proliferant therapy (prolotherapy).
Prolotherapy is a treatment for pain thought
to be due to ligament or tendon damage. I understand
that prolotherapy consists of a series of injections
administered at two or three week intervals.
The treatment is designed to induce ligament
and tendon healing.
I understand that although this treatment has
been in use since the 1950’s it is not
yet accepted as a “traditional” treatment
by many physicians and is considered experimental
by many insurance companies. There have been
several clinical trials of this treatment published
in the medical literature which have shown
that it is safe and effective and produces
significant improvements in a large majority
of patients. I understand that I cannot expect
a cure or have complete disappearance of pain
but a gradual improvement over a period of
months is likely but cannot be guaranteed.
I have looked into or tried the alternatives
of putting up with the pain or taking medication,
chiropractic adjustments, physical therapy,
I understand that there are risks associated
with any invasive procedure. In the 1960’s
there were several serious injuries including
death and paralysis associated with prolotherapy
but these were due to poor needle placement
using a different solution and injection technique
than used by Dr. Kochan. More common side effects
include local soreness and/or swelling, bleeding,
allergic reaction, pneumothorax (collapsed
lung), nerve damage, damage to bone or ligament
or tendon rupture.
My pain is long standing and severe and has
not responded significantly to any other
treatment. I have read this form and thought
it over and discussed the treatment with you.
By signing this form I do not relieve you from
exercising due care on my behalf, but I do acknowledge
and accept the risks involved.
Because this treatment is considered experimental
by some insurance companies (in particular,
Medicare and Blue Cross) proliferant therapy
may be denied coverage in which case I will
be financially responsible for the charges
This consent applies to any prolotherapy
injections administered in the future.
Signed: ________________________________ Date:
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