Healthcare Steroid Injection Consent Form

Healthcare Steroid Injection Consent Form

Patient Name:     Date of Birth:

Gender: Male Female Other Prefer not to say

Insurance Information

Medical History

Are you taking blood thinners or anticoagulants? Yes No

Procedure Description

Proposed Procedure: Injection of corticosteroid and local anesthetic to targeted structure for management of pain and inflammation. Injection Site:

Provider performing procedure:    Planned date:

Risks, Benefits, and Alternatives

I understand the intended benefit of this procedure is reduction of pain and inflammation in the targeted structure and improved function. I understand alternatives to corticosteroid injection include oral medications, physical therapy, activity modification, bracing, and surgical intervention where appropriate.

Potential risks and complications include, but are not limited to: infection, bleeding, increased pain at the injection site, nerve injury, allergic reaction to medication or contrast, transient increase in blood glucose, facial flushing, skin discoloration or thinning, tendon weakening or rupture, post-injection flare, systemic steroid effects, and rare complications including avascular necrosis. If image guidance (fluoroscopy/ultrasound) is used, there are additional small risks related to imaging.

I understand there is a risk of infection.
I understand there is a risk of bleeding or hematoma.
I understand there is a risk of nerve injury or paresthesia.
I understand systemic steroid effects may occur (e.g., elevated blood sugar, mood change).

Pre-Procedure Instructions

You must notify the office immediately prior to the procedure if you are pregnant, have an active infection, have recently taken blood-thinning medication, or have had a recent change in your medical condition. If you have diabetes, your blood glucose may rise and you should monitor levels closely following injection.

HIPAA / Privacy Acknowledgment

I acknowledge that I have been provided information regarding the use and disclosure of my protected health information for treatment, payment, and health care operations, and that my information may be shared with other healthcare providers involved in my care as necessary.

Acknowledged: Yes

Authorization Expiration Date:

Consent and Certification

I certify that the information I have provided on this form is true and complete to the best of my knowledge. I understand the nature of the procedure, the expected benefits, material risks, and reasonable alternatives. I have had an opportunity to ask questions and my questions have been answered to my satisfaction.

By signing below I voluntarily consent to the performance of the steroid injection and related procedures as described above, including the administration of local anesthetic and corticosteroid, and the use of image guidance if deemed necessary by the provider.

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