Informed consent for intrathecal drug delivery system (pain pump) trial and/or implantation, covering catheter placement, drug selection, refill schedule, device risks, and granuloma risk.
The Intrathecal Drug Delivery Pump Informed Consent is a ready-to-use healthcare & wellness template you can send for signature in minutes. It is written for 1 signer (patient) and, by default, expires 30 days after it is sent if left unsigned. It covers consent, pain management, intrathecal pump, pain pump, neuromodulation, interventional pain. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# Intrathecal Drug Delivery Pump Informed Consent > **Important — not medical advice.** For use by a licensed provider; tailor to the patient, your protocols, and state law. **Provider / Practice:** ___________ **Patient Name:** ___________ **Date of Birth:** ___________ **Medical Record Number:** ___________ --- ## 1. Procedure Proposed **Procedure:** ___________ **Device Manufacturer / Model:** ___________ **Planned Intrathecal Drug(s):** ___________ **Catheter Tip Target Level:** ___________ **Performing Surgeon / Clinician:** ___________ **Facility / Location:** ___________ --- ## 2. Indication **Diagnosis / Reason for Procedure:** ___________ Intrathecal drug delivery delivers medication directly into the cerebrospinal fluid (CSF) surrounding the spinal cord, achieving therapeutic drug concentrations at the target site at a fraction of the systemic dose. This approach is considered when pain or spasticity is refractory to conventional treatments, or when systemic medication side effects are intolerable. --- ## 3. Description of the Procedure