Patient Information and Consent Form

Your details (Page 1 of 4)
The details you provide in this form will be used to arrange your consultation and understand your health needs. Your personal details may be used to contact you about important information relevant to your appointment/condition and invite you to provide feedback. Please see our full terms & conditions at https://www.mskultrasoundinjections.co.uk/terms-and-conditions for more information about our privacy policy.
We would like to contact you regarding information/updates that we believe are relevant to you/your health. This can include but not limited to changes in the location or circumstances of our clinic, if we start providing a new service, or if we start providing our services at an additional or alternative location.
Name*

TitleFirst NameLast Name
Date of Birth*

DayMonthYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile/phone number*
E-mail Address

Confirmation Email
Have you been referred to us or seen by a specialist prior to your appointment. This can be your GP, a physiotherapist or a hospital specialist (like an orthopaedic surgeon, a rheumatologist or a sport medicine doctor).

YesNo
Who referred you to us?*
If you have a written referral for an ultrasound guided injection or procedure (from your GP, a physiotherapist or a hospital specialist). Please attach a copy of the written referral to the submission.
What is the referral for?*
Payment method*

Self-payPrivate health insurance
Please give us details about your diagnosis/medical problem (including the side)*
Have you had previous relevant imaging/scans (like X-ray, CT or MRI) to the area? If yes, please give us more details (approximate date of scan and summary of findings).
If you have any file(s) you want to share with us (for exmaple imaging reports), please upload them here...

Cancelof
Kindly note it would be useful to wear comfortable clothing that allows easy exposure of the body part being scanned or treated (like your shoulder or knee)

Procedure/injection information (Page 3 of 4)
The links below provide information regarding the procedures we commonly perform. If applicable, please choose one of the links relating to your proposed treatment which will open the information leaflet in a new window so you can view and download.

It is very important that you read this information before your appointment. You will have plenty of opportunity to further discuss the procedure and ask any questions at the time of consultation.

Musculoskeletal ultrasound injections clinic Patient Information: Steroid Injection

Musculoskeletal ultrasound injections clinic Patient Information: Hydrodilatation Injection

Musculoskeletal ultrasound injections clinic Patient Information: Barbotage/lavage for calcific tendonitis

Musculoskeletal ultrasound injections clinic Patient Information: High volume Achilles tendon injection

Musculoskeletal ultrasound injections clinic Patient Information: Baker's cyst aspiration/steroid injection

Musculoskeletal ultrasound injections clinic Patient Information: Ganglion cyst aspiration/steroid injection

Musculoskeletal ultrasound injections clinic Patient Information: Durolane/Hyaluronic acid injection

Musculoskeletal ultrasound injections clinic Patient Information: Arthrosamid injection
Please confirm that you have read and understood the supplied online patient information leaflet*
COVID-19
Steroid injections may reduce the person's immunity for 2-4 weeks following injection. The reduction in immunity for most people is likely to be small and it is unclear if this has any impact on their risk of contracting COVID-19. The emerging data now suggests that the risks are probably very low (Regan et al 2021 and McKean et al September 2020).
Do you have any of the following risk factors (for severe COVID):

Age over of 70BAME (Black, Asian or minority ethnic background)DiabetesIschaemic heart diseaseChronic respiratory diseaseHypertension
A steroid injection may temporarily inhibit the immune response to the COVID-19 vaccine. We are following the guidance published by 'Arthritis and musculoskeletal alliance' arma.uk.net/covid-19-vaccination-and-msk which recommends a gap of 2 weeks after the vaccine before having a steroid injection in order to allow a full immune response. We therefore advise not to perform a steroid injection within two weeks on either side of the date a patient has received a vaccine. It is also advisable to leave a two-week gap on either side of a seasonal flu vaccine also.

COVID-19 precautions (Page 4 of 4)
Do you have symptoms of COVID-19, or had symptoms in last 14 days?*

YesNo
Does anyone of your household have symptoms of COVID-19, or had symptoms in last 14 days?*

YesNo
The musculoskeletal ultrasound and injections clinic (and physio and more) take all reasonable steps to minimise any risks to patients contracting COVID-19, including observing social distancing, infection control and PPE guidelines. However, ultrasound scan assessment and injection treatment requires close physical contact (less than 2m for more than 15 mins) which may increase risks of exposure and transmission of COVID-19. We ask all patients to provide consent that they are aware of this issue.
Please confirm that you have read and understood the information provided in this form, including the COVID-19 precautions*
Signature (Please place the mouse cursor in the signature box, click and hold the left mouse button, then move the mouse as if you were drawing)*
Date*

DayMonthYear
Date
Should be Empty:

Your details (Page 1 of 4)

Relevant clinical information (Page 2 of 4)

Procedure/injection information (Page 3 of 4)

COVID-19

COVID-19 precautions (Page 4 of 4)