VISCOELASTIC (SODIUM HYALURONATE) INJECTION CONSENT FORM
PATIENT NAME : |
| GENDER: | DOB : |
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Procedure: | Hyaluronic Acid (sodium hyaluronate) Injection into:
……………………………………………………………………………………….. |
The Intended Benefits: |
Reduced pain, increased mobility |
Possible Risks:
Contra-indications: (unable to inject if any of these are present) |
Allergic reaction, bleeding, bruising, fainting, infection, post-injection pain, nerve injury, vascular damage, bleeding in to the joint, no benefit, recurrence of problem.
Generalised or local Infection, local skin lesion or a replacement joint at injection site, uncontrolled anticoagulation (blood thinners) or diabetes, pregnant or breast feeding, history of allergy to injection materials. |
I have also discussed what the procedure is likely to involve, and the benefits/risks of any available alternative treatments (including no treatment i.e. option to do nothing).
Failure of first line conservative measures Yes No
Risk/benefit of Sodium Hyaluronate injection discussed Yes No
Absence of Contraindications noted above Yes No
Information leaflet provided Yes No
Injection Details
Product | Dose | Dose Delivered | Batch Number | Expiry Date |
Ostenil Plus ® (20mg/1ml) | 2 mls |
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Ostenil mini ® (10mg/1ml) | 1ml |
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Ostenil tendon ® (20mg/1ml) | 2mls |
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Monovisc ® (22mg/1ml) | 4mls |
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Cingal ® (22mg/1ml+18mgTH) | 4mls |
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Does the patient appear to have the capacity to consent to the treatment/procedure YES / NO
INFORMED CONSENT
I, the above-named person, have read and understood the information on this form. I have been given the necessary time to ask questions about the above possible risks of a viscoelastic (sodium hyaluronate) injection and I am happy to proceed. I have considered my individual risks and I understand that there is no guarantee of outcome. I consent to the injection procedure detailed above.
PATIENT SIGNATURE: |
| DATE: |
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INJECTION THERAPIST | NAME - PRINT | STEPHEN BUNTING | DATE: |
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SIGNATURE: |
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