LSRI Consent Form

LSRI procedure Consent Form
Patient Information
Name*

First nameSurname
Date of Birth*

DayMonthYear
Gender
Email*
Primary Phone Number

Country CodeArea CodePhone Number
Medical Data

Part A: Patient checklist: Please complete this part before an appointment*

Rows	Yes/No
Do you have any allergies?
Are you on any Blood thinners ?
Are you in any Anti retroviral therapy ?
Are you Diabetic ?

Do you have any known allergies? If yes, then please specify below.
Are you currently taking medications? If yes, then please list the medications and the reasons why are you taking them.
What is your current medical condition? Do you have any communicable disease, cardiovascular problems, diabetes, asthma etc.?
PART B:

Common side effects of injections are:

1. Pain, flare up, bleeding and bruising

2. Depigmentation, fat atrophy and skin thinning

4. Infection

5. Nerve, tendon and surrounding structure damage

6. No effect

7. Right- or left-hand dominance - given the risk or pain and /or discomfort, please make sure you understand the consequences of increased pain due to steroid flare on your work and
life.

More detailed information leaflet is here:

Injection information leaflet

By signing the form, you confirm the following statements

1) I confirm that I have read and understood the musculoskeletal injection information leaflet and consent to undergoing the injection and procedure.

2) I understand the risks and side effects mentioned in the information leaflet.

3) I have considered the effects of complications and side effects of the injection and procedure on my employment, social or personal life.

4) I also understand that I have the option of not undergoing or refusing this injection or procedure.
PART C: Proposed treatment
Please note this can be changed as per discussion at the time of appointment
I authorise the clinic and treating doctor to perform the treatment or necessary procedure to me/ or to my (for Parent/Guardian) dependent.I authorise the use of anesthesia and understands the side effects I can experience from it.I understand the risk and complications if I do not follow the instructions given to me after the procedure which involves treatment and follow-ups.I acknowledge that all information I provided in this form is true and accurate.
Patient/Parent/Guardian Signature*
Doctor's Signature

Please do not sign here
Date Signed*

DayMonthYear
Date Signed by the doctor

DayMonthYear
Should be Empty:

LSRI procedure Consent Form

Patient Information

Medical Data