Injections Consent

Injection Consent form to be filled out prior to attending treatment at Meyer & Associates.

Patient First and Last Name

Patient Email Address

Telephone Number

Date of Birth

Address Line 1

Address Line 2

(Optional)

Town

Post Code

Referring Consultant/GP & Address (Please include GP address even if not directly referred by the GP)

Have you ever suffered any ill-effects after a local anaesthetic procedure, for instance after an injection or dentistry procedure?

Yes No

Do you have any allergies?

If yes please specify?

Yes No

Do you suffer from Type 1 or Type 2 Diabetes?

Yes No

Do you suffer of any bleeding disorders or use blood thinning agents, for example Warfarin or Apixaban?

Yes No

Do you have a pacemaker, heart condition or blood pressure problems?

Yes No

Are you pregnant or breastfeeding?

Yes No

Have you suffered from any infections or had Covid-19 in the last 4 weeks?

Yes No

Have you received any vaccines (including Covid-vaccine) within the last 2 weeks?

Yes No

Injections for musculoskeletal conditions are generally safe but not entirely without risk.
Complications are rare and mostly not serious.
Very rare complications may include infection or allergic reactions.
Rare complications may include skin depigmentation, soft tissue thinning and fat necrosis, blood vessel or nerve injury and tendon rupture (more common with multiple injections).
Occasional complications may include facial flushing, the area that feels painful afterwards (flare) or bleeding and bruising.

AFTERCARE:
Do not drive if you do not feel fit to do so.
Relative rest after the injection , avoiding vigorous activity or sport.
Don't delay contacting GP or dial NHS 111, if signs of infection that include a joint that feels swollen, hot and painful.
Seek immediate help or dial 999 in case of an allergic reaction/rash/breathing difficulty.

COVID-19:
No COVID-vaccination dose for 2 weeks, either side of the injection.
Be aware of potential risk of reduced immunity and lack of clear evidence related to COVID-19, at the present time.

CONSENT:
I consent to the injection procedure as described to me by the clinician.
I have understood the information detailed above and had an opportunity to ask questions and understand fully the reasons for the procedure

I confirm that all information provided is correct and give consent to the injection procedure as described to me by the clinician. I have understood the information detailed above have had an opportunity to ask questions and understand fully the reasons for the procedure at Meyer & Associates Sports Physiotherapists.

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