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.
Various medications, vitamins, minerals, platelet-rich plasma, stem cells or ozone can be injected directly into tissue such as a tendon, bursa or joint, or intramuscular for a systemic effect.
_____ Possible side effects include allergic reaction, immediate pain at the injection site, infection, bleeding, bruising, and weakening of tendons.
_____ Possible side effects include worsening of pain in the injected joint or joints in general.
_____ About 1 out of 10 patients will experience a post-injection flare due to your immune system being hyper-stimulated. This may make the first 24-48 hours after the injection very painful.
_____ Rare complications may include damage to nerve or blood vessel, frozen joint or tendon rupture.
_____ Rare complications of spine injections may include puncture of spinal canal, herniation of the brainstem, accidental puncture of the aorta or vena cava leading to retroperitoneal hematoma, accidental puncture of the spinal cord from being in wrong location, infection being introduced into the subarachnoid space.
_____ 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 joint injection performed.
Patient / Legal Guardian Signature / Date:
Medical Assistant/Nurse/Physician / Date:
