Please read this form entirely. It contains information to assist you in making a decision to have a specific therapy. Initial each paragraph if you understand it. If you do not understand it, do not initial it and each paragraph will be discussed with you separately. There are risks and complications that may result from this therapy, they are rare, but do exist and you must be aware of them.
Steroids are the name used to describe a group of drugs correctly known as corticosteroids. Steroids are used to treat inflammation. Steroids can be injected directly into tissue such as a bursa or joint, or intramuscular for a systemic effect.
_____ Possible side effects include allergic reaction, immediate pain at the injection site, transient increase in pain at the injection site for several days, infection, bleeding, bruising, localized thinning or depigmentation of the skin, thinning of subcutaneous fat resulting in dimpling, and weakening of tendons. Steroids may cause a transient increase in blood sugar.
_____ Rare complications include avascular necrosis (bone death), steroid arthropathy / damage to the joint, damage to surrounding nerves, and systemic reactions such as palpitations, hot flashes, adrenal suppression, irregular menstrual bleeding, or mood changes including anxiety, insomnia or psychosis.
_____ The above listed risks may occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate hospitalization and/or extended outpatient therapy to permit adequate treatment.
_____ I understand that medicine is not an exact science and that no guarantees are offered regarding my expected results. I am aware that it is possible that this treatment will not work for me.
I have read the foregoing information, it has been explained, and I understand it. All of my questions have been answered. By executing this form, I am indicating that I have no questions whatsoever and I give my full informed consent to have Steroid injection performed.
Patient / Legal Guardian Signature / Date:
Medical Assistant/Nurse/Physician / Date: