First name
Last name
Date of birth
Street Address
City
Postal Code
Please indicate region to be injected.
Please note – We do not offer injections for the face, neck or spinal conditions (neck, ribs, sacroiliac joint (SIJ) and lower back).*
Select a region
Diagnosis
Have you had, or are you waiting for surgery for the area to be injected (Please provide approximate dates)
Occupation
GP Name
GP Address
GP City
GP Postal Code
Please list any past medical history (e.g. diabetes, high blood pressure etc.)
Please list any medication that you are currently taking
You should not have an injection if you currently have an infection anywhere in your body which requires treatment from antibiotics. If you have recently been treated for an infection you should wait 10 days after you have finished your antibiotics and/or have been cleared of the infection before receiving an injection. If you are unsure you must check with your GP if they are happy for you to have an injection.
Are you currently taking, or have you recently finished, a course of antibiotics?
If yes, please give name of antibiotic, the dosage and reason for taking this medication.
Do you have diabetes?
If yes, is your diabetes controlled with:
Is your diabetes well controlled?
Do you take any blood thinning (anti-coagulant) medication?
If yes, please list:
Do you know your INR (International Ratio which would be monitored via your anti-coagulant clinic)?
Do you have primary open angle glaucoma (POAG)?
Do you have any known drug allergies?
If yes, which drugs have you had a reaction to in the past and what were your symptoms from that reaction:-
Could you currently be pregnant?
Do you suffer from Haemophilia and/or any other blood disorder?
Are you currently under investigation OR having treatment for Cancer?
You should have been sent a patient information leaflet outlining potential risks and side affects relating to your proposed treatment. It is very important that you have read this information before your appointment so you have opportunity to ask any further questions which you may wish to clarify.
I have read and understood the potential side effects and risk associated with the injection treatment.
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