Reception: Steroid Injection Consent Form

Please complete this form if you are interested in having a steroid injection at the practice. Prior to completing the form please review in full the information in the link below outlining the benefits and risks of the procedure.

Information on Steroid Injections

Please do not write any clinical queries on this form. Any clinical queries or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception 01926 331401. We will start to process your form by the next working day but it will take up to 7 working days to complete. Please DO NOT call before 7 working days as you will not receive a status update from reception or the administrative team. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over.

Full Name:

Date of Birth (DD/MM/YYYY):

Contact Number (Preferably Mobile):

Location of InjectionOnly one joint can be done at one time.

I understand that the steroid injection is for symptom control and NOT a cure of the underlying illness

The potential risks of the procedure include, bleeding, infection (Skin or joint), Lightening of the skin, tendon rupture, and recurrence of the symptoms (Failure of the treatment). If you select the option 'I do not want to go ahead' you will not be booked for a steroid injection and you can abandon this form

What is your current smoking status?

How many units of alcohol do you consume per week?

Allergies (if none, state 'none' below):

Are you taking any blood thinners?Please note aspirin & clopidogrel are not blood thinners. They are anti-clotters (anti-platelets).

I understand that a steroid injection increases my risk of suffering worse outcomes from an infection (Including COVID19) and that this risk remains for 4-8 weeks after the injection.

I am happy to be contacted by telephone to discuss my suitability for a steroid injection with a doctor if deemed requiredPlease note not all patients will need to be contacted. This will be done on a case by case basis.

I confirm that I have not had my COVID vaccine in the last 4 weeks or am due to have it in the next 4 weeksHaving a steroid injection 4 weeks before or after the COVID vaccine can lead to a poor response and impact your protection

Please note: if you experience a fever (>37.8C) or a persistent cough (>4 hours) do not attend your appointment at the surgery

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Clarendon Lodge Medical Practice • Clarendon Lodge, 16 Clarendon Street, Leamington Spa, Warwickshire, CV32 5SS.

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