GENERAL INJECTION & INFUSION CONSENT

I hereby authorize the providers and staff at Alexander Medical to perform injections and/or intravenous infusions as recommended for my care, which may include (but are not limited to): 

• Intramuscular or subcutaneous injections (e.g., vitamin B12, testosterone, vaccines, medications)
• Intravenous infusions (e.g., IV fluids, vitamins, medications)
• Other therapeutic injections or infusions as clinically indicated

Risk and Potential Complications
I understand that while complications are uncommon, I understand that risks exist with any injection or infusion procedure. These may include, but are not limited to:

• Pain, soreness, or discomfort at the injection/IV site
• Bleeding or bruising
• Swelling or inflammation
• Infection (local or systemic)
• Damage to nerves, blood vessels, or surrounding tissues
• Allergic reaction or anaphylaxis
• Dizziness, fainting, or vasovagal response
• Temporary worsening of symptoms
• Lack of improvement or treatment failure
• Rare but serious events such as blood clots, embolism, or severe allergic reaction requiring emergency medical care 

Alternatives
I understand that alternative treatments exist and may be discussed with my provider. I may decline injection or infusion therapy at any time. 

Patient Responsibilities
I agree to:

• Inform my provider of all medications, allergies, and medical conditions prior to treatment.
• Follow all post-treatment instructions provided.
• Report any concerning symptoms immediately (e.g., fever, spreading redness, severe pain, or difficulty breathing).
   

Acknowledgement
I acknowledge that I have had the opportunity to ask questions about the procedure(s), risks, benefits, and alternatives, and that all questions have been answered to my satisfaction.

CONSENT FOR TRIGGER POINT INJECTIONS

Trigger Point Injections (TPI) are used to treat extremely painful and tender areas of muscle. A small needle is inserted into the trigger point and a local anesthetic (e.g., lidocaine, procaine, bupivacaine) is injected. This procedure inactivates the trigger point to alleviate pain.

The details of the procedure have been explained to me in terms I understand. Alternative methods and their benefits and disadvantages have been explained to me. I understand and accept that there are complications, including the remote risk of death or serious disability that exists with any surgical procedure. I understand and accept the most likely risks and complications of trigger point injections, which include but are not limited to:

• Pneumothorax/Collapsed Lung
• Infection
• Needle Breakage
• Numbness
• Trauma to Nerves
• Vasovagal Reaction (fainting)
• Soft Tissue Swelling, Bruising or Hematoma 

I understand and accept the anticipated outcomes:

• Increased circulation to the muscles
• Increased exercise tolerance
• Increased pain threshold at the trigger point
• Increased range of passive and active motion
• Pain Reduction
• Multiple sessions may be necessary
• Temporary increased muscle spasm
• Temporary injection and post-injection pain
   

Patient Acknowledgment

I have informed the licensed healthcare provider of all my known allergies, all medications I am currently taking, including prescription drugs, over-the-counter remedies, herbal therapies and supplements, aspirin and any other recreational drug or alcohol use. I have been advised whether I should avoid taking any or all of these medications on the days surrounding the procedure. I have been informed of what to expect in the post-injection period, including but not limited to: estimated recovery time, anticipated activity level and the possibility of additional procedures. The physician has answered all of my questions regarding this procedure.

Should trigger point injections be recommended and offered as part of my care, I certify that I have read and understand this treatment agreement. I authorize my licensed healthcare provider, with associates or assistants of his/her choice, to perform the procedure. I authorize the licensed healthcare provider(s) and assistant(s) to perform this procedure for a series if indicated. I further authorize the licensed healthcare provider(s) and assistant(s) to perform this or any other procedure that, in their judgment, may be necessary or advisable should unforeseen circumstances arise during the procedure.

CONSENT FOR STEROID INJECTION

Please read this form entirely. It contains information to assist you in making a decision to have a specific therapy. Initial each paragraph if you understand it. If you do not understand it, do not initial it and each paragraph will be discussed with you separately. There are risks and complications that may result from this therapy; they are rare, but do exist and you must be aware of them.

Steroids are the name used to describe a group of drugs correctly known as corticosteroids. Steroids are used to treat inflammation. Steroids can be injected directly into tissue such as a bursa or joint, or intramuscular for a systemic effect.

• Possible side effects include allergic reaction, immediate pain at the injection site, transient increase in pain at the injection site for several days, infection, bleeding, bruising, localized thinning or depigmentation of the skin, thinning of subcutaneous fat resulting in dimpling, and weakening of tendons. Steroids may cause a transient increase in blood sugar.
• Rare complications include avascular necrosis (bone death), steroid arthropathy/damage to the joint, damage to surrounding nerves, and systemic reactions such as palpitations, hot flashes, adrenal suppression, irregular menstrual bleeding, or mood changes including anxiety, insomnia, or psychosis.
• The above listed risks may occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate hospitalization and/or extended outpatient therapy to permit adequate treatment.
• I understand that medicine is not an exact science and that no guarantees are offered regarding my expected results. I am aware that it is possible that this treatment will not work for me.
   

I have read the foregoing information, it has been explained, and I understand it. All of my questions have been answered. If a steroid injection is offered to me as part of my care, I consent to proceed with the treatment.

CONSENT FOR PLATELET-RICH PLASMA (PRP) THERAPY

I give my informed consent for the Platelet-Rich Plasma (PRP) therapy procedure. I understand the following:

1.  PRP therapy involves drawing a small amount of my blood, processing it to concentrate the platelets, and injecting the resulting PRP into the treatment area.
2. The purpose of PRP therapy is to promote healing and enhance tissue repair in the targeted area.
3. I understand that there may be risks and potential side effects associated with PRP therapy, including but not limited to infection, pain, swelling, bruising, and allergic reactions.
4. The expected benefits, risks, and alternatives to PRP therapy have been explained to me, and I have had the opportunity to ask questions and voice any concerns.
5. I acknowledge that the outcome of PRP therapy can vary from person to person, and there is no guarantee of specific results.
6. I consent to the PRP procedure being performed by the healthcare provider, and I understand that unforeseen circumstances may require adjustments to the treatment plan.
7. I agree to follow any post-procedure instructions provided by the healthcare provider to optimize the results and minimize complications.
8. I understand that I have the right to withdraw my consent at any time before or during the PRP therapy procedure.
    

I understand the information provided, and if PRP therapy is offered to me as a treatment option, I consent to proceed with the therapy at that time.

ACKNOWLEDGMENT

I have read (or had read to me) this entire consent. I have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction. I acknowledge that I have read, understood, and agreed to all sections of this Comprehensive Injection & Infusion Consent, and I agree to the policies of Alexander Medical.

A copy of this entire agreement can be provided electronically or printed if requested.