Corticosteroid Injection Consent Form

CORTICOSTEROID INJECTION CONSENT FORM

                   

PATIENT NAME :

GENDER :

DOB :

 

 

Procedure:	Injection of steroid +/- local anaesthetic into:      ……………………………………………………………………………………….
The Intended Benefits:	Reduced pain, increased mobility
Possible Risks:             Contra-indications:	Allergic reaction, bleeding, bruising, facial flushing, fainting, infection, menstrual irregularity, post injection pain, rise in blood sugar in diabetics for a few days, rise in blood pressure for a few days if you have high blood pressure, soft tissue damage (permanent dimples) skin de-pigmentation, nerve injury, vascular damage, bleeding in to the joint, tendon rupture, no benefit or short term benefit only, recurrence of problem, small increased risk of catching viral and bacterial infections.   Generalised or local Infection, local skin lesion or a replacement joint at injection site, uncontrolled anticoagulation (blood thinners) or diabetes, live vaccination in last 2 weeks, pregnant or breast feeding, major surgery in the last 6 weeks or planned in the next month, history of allergy to injection materials.

 

I have also discussed what the procedure is likely to involve, and the benefits/risks of any available alternative treatments (including no treatment i.e. option to do nothing).

 

Failure of first line conservative measures                                      Yes                  No

Risk/benefit of corticosteroid injections discussed                         Yes                  No

Absence of Contraindications noted above                                     Yes                  No

Information leaflet provided                                                            Yes                  No

 

Injection Details

Medication	Dose Range	Dose Delivered	Batch Number	Expiry Date
Depo-Medrone with Lidocaine (methylprednisolone acetate 40mg/1ml with lidocaine hydrochloride 10mg/1ml))	4 – 80 mg (of steroid)
Depo-Medrone (Methylprednisolone acetate 40mg/1ml)	4 – 80mg
Kenalog (triamcinolone acetonide 40mg/1ml)	4 – 80 mg
1% Lidocaine Hydrochloride	0 – 10 mls

 

Does the patient appear to have the capacity to consent to the treatment/procedure    YES / NO

 

INFORMED CONSENT

 

I, the above-named person, have read and understood the information on this form. I have been given the necessary time to ask questions about the above possible risks of a corticosteroid and / or local anaesthetic injection and I am happy to proceed. I have considered my individual risks and I understand that there is no guarantee of outcome. I consent to the injection procedure detailed above.

 

PATIENT SIGNATURE :

DATE :

 

INJECTION THERAPIST	NAME - PRINT	STEPHEN BUNTING	DATE :
	SIGNATURE :