Patient Forms

Injection Consent Form

Please review and complete before your injection procedure.

For your privacy, this form is not submitted online. Complete it here and print it to bring to your appointment, or simply complete it at our office — our team will be glad to help. Please do not email completed medical forms. Questions? Call 561-202-8886.

Patient & Procedure

Patient Name

Date of Birth

Medication / Injectable Name

Injection Site (e.g., knee, shoulder)

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, and had the opportunity to ask questions.

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

Authorization

Patient / Guardian Signature (type full name)

Printed Name

Relationship to Patient (if applicable)

Date