Dr Matteo Bernardotto Spinal Injection Consent Form

Are you a new or existing patient of Complete Injections?

Name

PrefixFirst NameLast Name

Have you changed address since the previous use of this form?

Address

Street Address

Street Address Line 2

CityCounty

Post Code

Change of Address

Street Address

Street Address Line 2

CityCounty

Post Code

Has your telephone number changed?

* Please enter either a landline or mobile number below. This is required if we need to contact you about the information you provide on this form. Your private data will not be shared with any third party.

Your Mobile Number

Mobile phone number

Your New Mobile Number

Mobile phone number

Your Landline Number (unnecessary if mobile number provided)

Area CodePhone Number

Your New Landline Number (unnecessary if mobile number provided)

Area CodePhone Number

Has your email address changed?

Email

New Email Address

Date of Birth

DDMMYYYY

Date now

DayMonthYear

Your Age

*Please note we are unable to offer injections to patients below 18 years of age.

Please indicate region to be injected.

*Please note: To be eligible for a spinal injection, you must have had an MRI scan of the area to be injected within the last 12 months.

Date of most recent MRI scan

Results/ report of that MRI scan?

Have you had any other scans or investigations of this region?

If 'Other' selected above, please state what scan or investigation you had.

What year was the scan?

Results of that scan?

Diagnosis

Please state the diagnosed condition for which you are to be treated.

Have you had, or are you awaiting surgery for the area to be injected? (Please provide approx. dates)

Please provide approximate dates.

*Please note: We do not offer injections into prosthetic joints (joints that have been replaced) or into an area where there is metalwork, screws or pins still in place from surgery. This is due to the raised risk of infection.

Please list previous treatments received for this issue e.g. physiotherapy, osteopathy, previous spinal injections, previous surgery

Have you changed your occupation since your last submission of this form?

Occupation

Have your GP details changed since your last submission of this form?

G.P.

Please type the name of your G.P.

Address of G.P. Surgery

Street Address

Street Address Line 2

CityCounty

Post Code

We recommend that you inform your GP that you will be attending for this consultation which may include local injection (e.g. glucocorticosteroid, local anaesthetic or hyaluronic acid). You will be sent a letter after the consultation outlining assessment findings and treatment including any medications used and dosage, this should also be passed on to your GP.

Has your medical history changed?

Please list any past medical history: (e.g., diabetes, high blood pressure, any surgery)

Please list any medications that you are currently taking:

Have you had a vaccine in the last two weeks, or are you expecting one in the next two?

We are unable to offer a steroid injection to patients within 2 weeks on either side of a COVID vaccine – please see below

Have you had the COVID vaccine in the last 2 weeks?

We are unable to offer a steroid injection to patients within 2 weeks on either side of a COVID vaccine – please see below

Steroids can temporarily reduce vaccine effectiveness. To ensure full protection from vaccinations—including COVID-19, travel, and seasonal jabs—please consult your GP or vaccination team. They will apply evidence-based guidelines on recommended time interval between your steroid injection and vaccines.

Are you currently taking, or have you recently finished, a course of antibiotics?

You should not have an injection if you currently have an infection anywhere in your body which requires treatment from antibiotics. If you have recently been treated for an infection you should wait 10 days after you have finished your antibiotics and/or have been cleared of the infection before receiving an injection. If you are unsure you must check with your GP if they are happy for you to have an injection.

If yes, please give name of antibiotic, the dosage and reason for taking this medication.

Do you have diabetes?

If you are Type 1 diabetic and/or your blood sugars are not always stable you must check with your GP if they are happy for you to have an injection (we recommend that patients with recent HbA1c above 8.5% (70mmol/mol) should obtain approval from their GP before booking). This relates to steroid injections only.

If yes, is your diabetes controlled with:

Is your diabetes well controlled?

Do you take any blood thinning (anti-coagulant) medication?

If yes, please list:

If you are taking an anti-coagulant such as a DOAC (direct oral anticoagulants) such as dabigatran, rivaroxaban, apixaban or edoxaban it is recommended you discuss with your GP regarding any changes to medication requirements around the time of your injection. Unfortunately we are not able to advise on this matter.

Do you know your INR (International Ratio which would be monitored via your anti-coagulant clinic)?

If your most recent INR was greater than 2.4 you must check with your GP if they are happy for you to have an injection.

Do you have primary open angle glaucoma (POAG) or diagnosed with raised IOP (intraocular pressure)?

Steroid injections may sometimes temporarily raise intraocular pressure, which can exacerbate POAG (primary open angle glaucoma). If you have glaucoma or raised intraocular pressure OR if you have suffered with visual disturbance after a steroid injection previously, you MUST discuss this with your GP before booking an appointment.

Do you have any known drug allergies?

If yes, which drugs have you had a reaction to in the past and what were your symptoms from that reaction:-

Could you currently be pregnant?

Unfortunately we are not able to offer injections to patients during pregnancy.

Do you suffer from Haemophilia and/or any other blood disorder?

AS YOU HAVE ANSWERED 'YES' TO THE ABOVE QUESTION, DISCUSS WITH YOUR GP OR HOSPITAL CONSULTANT BEFORE MAKING A BOOKING TO ENSURE ITS SAFE FOR YOU TO RECEIVE THE INJECTION TREATMENT. ANY FURTHER QUESTIONS PLEASE CALL 020 7482 3875 TO DISCUSS AFTER SUBMITTING THIS FORM.

Are you currently under investigation OR having treatment for Cancer?

AS YOU HAVE ANSWERED 'YES' TO THE ABOVE QUESTION, DISCUSS WITH YOUR GP OR HOSPITAL CONSULTANT BEFORE MAKING A BOOKING TO ENSURE ITS SAFE FOR YOU TO RECEIVE THE INJECTION TREATMENT. ANY FURTHER QUESTIONS PLEASE CALL 020 7482 3875 TO DISCUSS AFTER SUBMITTING THIS FORM.

Next of Kin

PrefixFirst NameLast Name

Next of Kin - Phone Number

Mobile phone number

Next of Kin - Relationship to you

Adverse Effects of Injections

Please see the Patient Information Leaflet below relating to spinal injection treatments. It is very important that you read this information before booking your appointment so you have the opportunity to ask any further questions that you may wish to clarify.

Please click on the link below, which will open the information leaflet in a new window for viewing and may also be downloaded:

Spinal Injection Patient Information: Spinal Injection

Please confirm that you have read and understood the supplied patient information leaflet:

I have read and understood the potential side effects and risk associated with the injection treatment.

Have you had COVID-19 in last 10 days?

Do you co-habit with a person who has had symptoms of COVID-19 in past 14 days?

Are you under current recommendation to either self-isolate or quarantine?

Please confirm that you consent for us to pass your email and telephone contact details to NHS track and trace service should we be required to do so (please note we will ever only pass on details if specifically asked to do so).

Clinic Location

Kentish Town Health Centre (James Wigg GP Practice),

2 Bartholomew Road, London NW5 2BX

The spinal injection clinic is situated on the ground floor. There is disabled access to the building and disabled toilet facilities.

How did you find us?

Pick one

Once we receive the completed form, this will then be screened by one of our senior clinicians. Once approved, one of our booking team will contact you to get you booked for an appointment – please note we aim to screen all consent forms within a maximum of 1-2 working days.

Signature

To draw your signature: Place the mouse cursor in the area below, click and hold the left mouse button then move the mouse as if you were drawing.