Prolotherapy Informed Consent Form

I, First & Last Name* , have been advised and consulted about the injection technique of Prolotherapy/Prolozone/Ozone. I understand the risks involved and that no guarantees as to results are to be assumed, and none to be implied from these types of therapies. The technique requires the injection of local anesthetic (Procaine, Marcaine, and/or Lidocaine), 25-50% Dextrose (sugar water), methylcobalamin (vitamin B12), ozone, and other solutions. The sight of the injection is where the ligament or tendon attaches to the bone, at the joint capsule, a trigger point, and/or inside the joint.

I understand the possible BENEFITS of the procedure are to improve or resolve pain and improve function. The procedures may initially increase pain in the area or worsen symptoms for one to three days and then decrease pain and symptoms but may not completely eradicate them. I understand that this treatment may not be covered by my insurance due to some insurance companies considering this treatment to be experimental and that I am responsible for the total charge of the treatment. I understand that healing does not always proceed in a predictable manner and may take many weeks or months to experience full effect.

I have been informed of that the ALTERNATIVES to Prolotherapy include:

Do Nothing
Steroid Injections
Surgical Intervention
Manipulation
Acupuncture

I have been informed that the RISKS and COMPLICATIONS of Prolotherapy include:

Immediate pain at the Injection Site
Bruising Allergic reaction to the solution
Itching at the injection site(s)
Stiffness in the injected joint
Swelling after joint injections
Injury to the nerve and/or muscle
Temporary or permanent nerve paralysis
Lung puncture or collapsed lung
Dizziness or fainting
Bleeding Spinal cord injury from back injections
Headache from back injections
Infection from the injection
Nausea/Vomiting
Death due to complications of the treatment
Temporary blood sugar increase
Treatment may be ineffective

I have been informed that the risks of NO Prolotherapy include:

No pain relief
Continued instability of damaged joint or ligament(s)
Worsening of painful condition or symptoms

I certify that I have read and fully understand the above consent form and that any questions have been answered to my satisfaction. I hereby authorize Joint Repair Clinic of MT to perform the recommended procedure. I understand that because treatment usually requires a series of injections, the same risks, as described above, will also apply to those subsequent treatments.

Patient Signature*

Clear

Patient Name*

First & Last

Date*

Date

Email

example@example.com