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Injection Informed consent

Clinical information and informed consent

Name *

Date of birth *

Date picker instructions: 1. Click in the date field. 2. Double click on the month and year shown above the calendar 3. You now see a year range i.e 2000-2009 4. Click on the arrow to the left to cycle through the decades 5. Once you found your decade then click on your year of birth 6 .Click on the month of birth 7. Now select the day

Address: *

Street

City/Town

Postcode

Phone *

Email *

How did you hear about us? *

Google

B&A Practice

Barnes Practice

Sonoworld

Other

Would you like us to forward a copy of the clinic letter to the GP? *

GP Name / Practice name

Only required if you opted to have the report send to your GP

Address:

Only required if you opted to have the report send to your GP

Street

City/Town

Postcode

Please describe your problem *

Diagnosis

How long has this problem been present for? *

Have you had any treatment? *

Was there an injury? *

What aggravates or eases your pain? *

Have you had any investigations? *

File 1. Please upload anything that might be helpful such as image reports as well as relevant reports from your doctor or specialist

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Max File Size: 5MB · Allowed File Types: jpg,png,pdf,docx,doc

File 2. Please upload anything that might be helpful such as image reports as well as relevant reports from your doctor or specialist

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Max File Size: 5MB · Allowed File Types: jpg,png,pdf,docx,doc

File 3. Please upload anything that might be helpful such as image reports as well as relevant reports from your doctor or specialist

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Max File Size: 5MB · Allowed File Types: jpg,png,pdf,docx,doc

Do you have any medical conditions? *

List of medications *

Are you currently on or have you recently been on antibiotics? If yes then please contact your GP to check if it is still ok for you to have a steroid injection *

Yes

Do you have diabetes? *

Yes

Have you had any hypo- or hyper glycaemic incidents in the last year? *

Yes

Do you have any drug allergies? *

Yes

If you answered yes to the previous question then what symptoms did you have?

Have you ever fainted or had a significant reaction to an injection? *

Yes

Could you currently be pregnant? *

Yes

COVID-19 and steroid injections

Steroid injections may temporarily reduce the immune response to the COVID Vaccine.

Please click here for the detailed and regularly updated ARMA (Arthritis and Musculoskeletal Alliance) guidance : http://arma.uk.net/covid-19-vaccination-and-msk/

Scroll down the ARMA webpage to item 13 which is the guidance on steroid injection and the COVID vaccine

Are you due to have the COVID vaccine in the next two weeks? *

Yes

Have you had the COVID vaccine in the last two weeks? *

Yes

Did you answer yes to either of the two questions above regarding COVID vaccination?

The steroid injection should be delayed. In order to mount good immune response following the COVID vaccine a steroid injection should not be carried out two weeks before or in a period of two weeks after the COVID vaccine.

Can you please confirm which information leaflet you have read?

Steroid injections

Hydrodistension Injections

Hyaluronic acid injections

COVID -19 declarations

Declarations

Please read the following COVID-19 specific declarations and confirm you have read and agree with each one by checking the box for each: (agreeing with the declarations by ticking the boxes is recommended /advisable but is at your personal discretion)

I currently do not have symptoms of COVID-19 and have not recently been in close contact with anyone who has COVID-19 symptoms.

My GP is aware of and/or supports the need for / has referred me for ultrasound guided steroid injection (please note that this is advisable but not necessarry. It is at your personal discretion)

I am aware that corticosteroid is an immune-suppressant and therefore may make me more likely to contract COVID-19, inhibit my bodies response to COVID-19 if I contract and potentially make me more contagious to others.

Other treatments have been tried and/or are not effective.

The risks and benefits for receiving a corticosteroid injection have been considered and discussed with my GP / relevant health care professional. (please note that this is advisable but not necessarry. It is at your personal discretion)

I believe it would be detrimental to my health and / or health of person(s) I care for if there were a delay to receiving corticosteroid injection treatment

Have you read the steroid injection information leaflet? *

I have read and I do understand the steroid information leaflet including the risks and side effects of steroid injections

Terms & Conditions

I accept the terms and conditions as stated on this website and I have ticked all the declarations (as is recommended but not compulsary) .

I have read and agree to the Terms and Conditions

Signature

Please write your signature in the box above

Please make sure that all the required (*) fields have been completed otherwise the form will not submit !

If you have problems submitting the form then contact us on: 07999 923844

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Injection Informed consent

COVID-19 and steroid injections

COVID -19 declarations

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