Elite Sports Medicine
INJECTION CONSENT FORM
Patient Name: *
Date of Birth: *
Injection Consent Form
Potential Risks & Side Effects (not all-inclusive):
  • Pain or discomfort at the injection site
  • Swelling, redness, or bruising
  • Infection
  • Bleeding
  • Allergic reaction
  • Temporary increase in pain
  • Nerve damage (rare)

I acknowledge that I have discussed the nature, purpose, and potential risks of the injection with my provider. I have had the opportunity to ask questions, and all questions were answered to my satisfaction.

I understand that while complications are rare, no guarantees have been made regarding the results of this injection.

Authorization

I certify that I have read, understood, and agree to the above consent statements. I authorize the medical staff of Elite Sports Medicine to provide evaluation and treatment as deemed necessary, including the administration of injections as indicated.

Patient/Guardian Signature *
Printed Name *
Relationship to Patient (if applicable)
Date *

Thank You!

Your injection consent form has been submitted successfully.