Injection Consent

Who may we thank for referring you?

List all medications and / or supplements, including herbs and vitamins you are currently taking (feel free to bring a copy of your medication list to your appointment).

Are you currently ill with a cold or the flu?
YesNo

Are you currently pregnant or breastfeeding?
YesNo

Have you previously had an injection?
YesNo

I am requesting an injection.

I understand with all injections, they may cause pain or redness at the site of injection although this is rare. sometimes you may also bruise at the site of injection. if you have any concerns after the injection with swelling or redness, please call the office immediately. if it is after hours, please go to the emergency room if you are having difficulty breathing or any other serious reactions.

I certify that everything on this form is true and correct to the best of my knowledge.

Patient Signature

Please prove you are human by selecting the Car.