Dr Matteo Bernardotto Spinal Injection Consent Form

Are you a new or existing patient of Complete Injections?*

New patientExisting patient

Name*

PrefixFirst NameLast Name

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

YesNo

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?*

YesNo

* 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?*

YesNo

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 - We do not offer injections for the face.

*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 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?

YesNo

Occupation

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

YesNo

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?*

YesNo

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

Please list any medications that you are currently taking:*

Are you having the COVID vaccine in the next 2 weeks?

YesNo

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?

YesNo

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

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 are therefore unfortunately not able to perform steroid injections within two weeks on either side of the date a patient has received a vaccine.

It may be advisable to leave a two-week gap on either side of a seasonal flu vaccine also.

We recommend discussing with your GP if you have any further concerns.

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

YesNo

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?*

YesNo

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:

DietTabletInjection

Is your diabetes well controlled?

YesNo

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

YesNo

If yes, please list:

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)?*

YesNo

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?*

YesNo

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?*

YesNo

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

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

YesNo

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?*

YesNo

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:*

Confirm

Please confirm that you have read and understood the patient information page regarding steroid injections during COVID: COVID-19 and corticosteroid injections

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

Accept

Have you had COVID-19 in last 10 days?*

YesNo

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

YesNo

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

YesNo

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).*

I consent to provide my contact details for the NHS track and trace service.

I currently do not have symptoms of COVID-19.I am aware that corticosteroid is an immune-suppressant and therefore may make me more likely to contract COVID-19, inhibit my bodies response to COVID-19 if I contract and potentially make me more contagious to others.

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*

I am the patient receiving treatmentI am signing on behalf of another person who will be receiving the treatment. I confirm that I am authorised to sign on their behalf and I have interpreted the information above to the patient to the best of my ability and in a way in which I believe s/he can understand.

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.*