Dr George Bownes Arthrosamid® 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 note: We only offer Arthrosamid^® injections for the knee joint.

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

YesNo

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?

YesNo

What was the date of the previous consultation with Dr George Bownes?

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 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. 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.

Arthrosamid^® must be administered with prophylactic antibiotics.

The following combination of oral antibiotics must be taken on an empty stomach 1-2 hours before the Arthrosamid^® injection is administered. 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:*

For patients without allergy towards penicillin: 1g of Flucloxacillin plus 1g of AzithromycinFor patients with known or suspected allergy towards penicillin: 600mg of Clindamycin plus 1g of AzithromycinFor patients with a known or suspected allergy towards penicillin: 1g of Azithromycin plus 400mg Moxifloxacin

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?*

YesNo

Do you have liver disease?*

YesNo

Do you have kidney disease?*

YesNo

Do you have cardiac arrythmias?*

YesNo

Do you have a history of clostridioides difficile infection (aka CDI or C Diff)?*

YesNo

Do you take warfarin?*

YesNo

Do you have a history of ulcerative colitis?*

YesNo

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

YesNo

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)?*

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*

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 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 Arthrosamid 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.

Please select the Complete Injections Clinic location below for your appointment with Dr George Bownes:*

CHELSEA SW10 (Monday-Friday)

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.*

Dr George Bownes Arthrosamid® Injection Consent Form

Clinic Location