• Dr George Bownes Arthrosamid® Injection Consent Form

    Ultrasound Guided Spinal Injections
  • Are you a new or existing patient of Complete Injections?*
  • Have you changed address since the previous use of this form?*
  • 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.

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  • Has your email address changed?*
  • Date of Birth*
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  • Date now
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  • *Please note we are unable to offer injections to patients below 18 years of age.

  • *Please note: We only offer Arthrosamid® injections for the knee joint.

  • Have you had a consultation with Dr George Bownes before?*

  • Please ensure you send across letters from consultant or other health care professional who has recommended you for this treatment and also bring them along to your consultation.

  • Was it for the same medical complaint?

  • *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 injections, previous surgery.
  • Have you changed your occupation since your last submission of this form?
  • Have your GP details changed since your last submission of this form?*

  • We recommend that you inform your GP that you will be attending for this consultation. 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?*
  • Are you having the COVID vaccine in the next 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

  • 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

  • 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?*

  • 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.

  • Prophylactic antibiotics are administered prior to your injection, as recommended by Arthrosamid®, to reduce the risk of infection. These are provided by Dr Bownes before the injection.

    • Please arrive for your injection one hour before your appointment time. The antibiotics are included in the cost of your procedure.
    • There are three possible options based upon any known allergies or tolerance issues.
    • Dosages may need to be adjusted in patients with co-morbidities; hospital pharmacist advice should be sought if necessary.
  • Please tick the appropriate option for the antibiotics to be prescribed ahead of your Arthrosamid® injection:*

  • These antibiotics achieve adequate tissue concentrations at the time of injection. Used as a single-dose prophylaxis, they should exert a negligible impact on resistance development. Their spectrum encompasses members of the aerobic and anaerobic (i.e., deep) skin flora, which may contaminate the injection procedure, notably staphylococci, haemolytic streptococci, and Cutibacterium (former Propionibacterium) spp.

     Dosages may need to be adjusted in patients with co-morbidities; hospital pharmacist advice should be sought if necessary.

  • Please answer yes or no to the following.

    If you answer ‘Yes’ to any of the questions, you must consult your GP before booking for Arthrosamid® injection. This is to ensure you are safely able to take the prophylactic antibiotics required prior to the Arthrosamid® injection.

  • Have you ever had an allergic reaction to antibiotic medication?*
  • Do you have liver disease?*
  • Do you have kidney disease?*
  • Do you have cardiac arrythmias?*
  • Do you have a history of clostridioides difficile infection (aka CDI or C Diff)?*
  • Do you take warfarin?*
  • Do you have a history of ulcerative colitis?*
  • Do you take any blood thinning (anti-coagulant) medication?*

  • 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.

  • 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?*
  • 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.

  • Patient information leaflet and details of any adverse effects of Arthrosamid® Injections

  • Please see the Patient Information Leaflet via link below relating to Arthrosamid injections. 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:

  • Arthrosamid® Click here: Patient Information Leaflet

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

  • 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?
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  • Clinic Location

  • 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*
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