Injection Consent Form - Sonoscope

About
Ultrasound Guided Injections
Services
Prices
Contact
News

Injection Consent Form

Please complete our clinical information and injection consent form before any treatment takes place.

Name*

Date of birth (DD/MM/YYYY):*

Street (including number)*

City/Town*

Postcode*

Phone *

Email *

How did you hear about us?*

Google

Physiotherapist

Electronic Screen Lister house MC

GP

Word of mouth

Via email

Other

Referring Physiotherapist*

Word of mouth*

GP *

Other*

Do you want us to email a copy of your clinic report to your Physiotherapist (or other health professional) ? (Please provide email address if available)*

Yes

No

Contact details: *

Please describe your problem*

Diagnosis

Area(s) to be injected

Please note we do not inject: The spine (neck, thorax - including ribs-, back and sacroiliac joint), the face

Please check the area(s) to be injected*

Shoulder

Elbow

Wrist / Hand

Hip

Knee

Ankle / Foot

Other

Have you had, or are you awaiting surgery for the area to be injected?

Yes

No

Please give approximate dates

Occupation

How long has this problem been present for?*

Have you had any treatment?*

Was there an injury?*

What aggravates or eases your pain?*

Have you had any investigations?*

Please upload anything that might be helpful such as image reports as well as relevant reports from your doctor or specialist

10 files maximum per upload. Maximum total file size: 50MB · Allowed File Types: jpg,png,pdf,docx,doc, MP4

Are you currently on or have you recently been on antibiotics? *

Yes

No

If yes then please contact your GP to check if it is still ok for you to have a steroid injection.

Do you have diabetes?*

Yes

No

Is your diabetes controlled with:*

Diet

Tablets

Insulin

Is your diabetes well controlled?

Yes

No

If you are Type 1 diabetic and/or your blood sugars are not always stable you must check with your GP if they are happy for you to have a steroid injection (we recommend that patients with recent HbA1c above 8.5% (70mmol/mol) should obtain approval from their GP before booking). This relates to steroid injections only.

Do you take any blood thinning medication? *

Yes

No

Please list medication

Do you have your INR measured in an anticoagulant clinic?

Yes

No

If your most recent INR was greater than 2.5 you must check with your GP if they are happy for you to have an injection.

Do you have glaucoma?

Yes

No

Company Name*

Steroid injection may sometimes temporarily raise intraocular pressure which can exacerbate Glaucoma. If you have suffered with visual disturbance after a steroid injection previously or you have glaucoma, we recommend that you discuss this with your Ophthalmologist before booking..

Do you have any other medical conditions?*

List of medications*

Do you have any drug allergies?*

Yes

No

If you answered yes to the previous question then what symptoms did you have?

Have you ever fainted or had a significant reaction to an injection?*

Yes

No

Could you currently be pregnant?*

Yes

No

Unfortunately we are not able to offer injections to patients during pregnancy.

Do you suffer from Haemophilia and/or any other blood disorder?

Yes

No

Please contact your haematologist to check whether you are able to have an injection.

Are you currently under investigation OR having treatment for Cancer?

Yes

No

Please contact your GP or oncologist and check whether injection therapy (steroid injection) is appropriate.

Are you due to have the COVID vaccine in the next two weeks? *

No

Yes

Have you had the COVID vaccine in the last two weeks?*

No

Yes

Did you answer yes to either of the two questions above regarding COVID vaccination?

The steroid injection should be delayed. In order to mount good immune response following the COVID vaccine a steroid injection should not be carried out two weeks before or in a period of two weeks after the COVID vaccine.

Have you read the steroid injection information leaflet?*

I have read and I do understand the steroid information leaflet including the risks and side effects of steroid injections

Please make sure that all the required (*) fields have been completed

otherwise the form will not submit !

If you have problems submitting the form then contact us on: 07999 923844

Can you please confirm which information leaflet you have read?

Steroid injections

Hydrodistension Injections

Hyaluronic acid injections

The spacious Sonoscope clinic is in a great location in the centre of Ware. We use high quality ultrasound equipment to obtain accurate diagnostic images and pinpoint accurate ultrasound guided procedures.

Sonoscope at The Dolphin Medical and Therapy Rooms.

6-7 East Street, Ware, SG12 9HJ

Clinic contact

info@sonoscope.co.uk
07999 923844

© 2026 Sonoscope

Terms and Conditions/