Arthrosamid Injection Consent Form - Sonoscope

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Arthrosamid Injection Consent Form

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

Name*

Are you an existing Sonoscope client or a new client?*

Existing Sonoscope Client

New Client

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

Street (including number)*

City/Town*

Postcode*

Phone *

Email *

How did you hear about us?*

I am an existing Sonoscope client

Google

Physiotherapist

Electronic Screen Lister house MC

GP

Word of mouth

Via email

Other

Referring Physiotherapist*

Word of mouth*

GP *

Other*

Google

Sonoscope website

Through Arthrosamid website and Sonoscope got in touch

GP Details

We recommend that you inform your GP that you will be attending for this consultation. You will be sent a letter after the consultation outlining assessment findings and treatment including any medications used and dosage, this should also be passed on to your GP.

GP Name

First

Last

Street (including number)*

City/Town*

Postcode*

Phone *

Email *

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

GP email: *

Diagnosis

Please check the area(s) to be injected*

Please note we offer Arthrosamid injections only for the knee joint  Please note: we do not offer injections into prosthetic joints (joints that have been replaced) or into an area where there is metalwork, screws or pins still in place from surgery. This is due to the raised risk of infection. Please check the area(s) to be injected*

Left

Right

Have you had a consultation (other than in this clinic) for this complaint before?

Yes

No

Whom did you consult with?

Have you had any investigations for this problem before?

X-Ray

MRI

Ultrasound

Please describe any previous imaging findings here ( or instead upload any imaging reports with the upload button below)

How long has this problem been present for?*

What treatment have you had

Physiotherapy

Osteopathy / Chiropractic

Surgery

None

Was there an injury?*

Yes

No

Please describe what injury you had

What aggravates or eases your pain?*

Arthrosamid® must be administered with prophylactic antibiotics. The following combination of oral antibiotics must be taken on an empty stomach 1-2 hours before the Arthrosamid® injection is administered. There are three possible options based upon any known allergies or tolerance issues. Dosages may need to be adjusted in patients with co-morbidities; hospital pharmacist advice should be sought if necessary

Please tick the appropriate option for the antibiotics to be prescribed ahead of your Arthrosamid® injectionUntitled

For patients without allergy towards penicillin: 1g of Flucloxacillin plus 1g of Azithromycin

For patients with known or suspected allergy towards penicillin: 600mg of Clindamycin plus 1g of Azithromycinon

For patients with a known or suspected allergy towards penicillin: 1g of Azithromycin plus 400mg Moxifloxacin

Website URL*

Please answer yes or no to the following. If you answer ‘Yes’ to any of the questions, you must consult your GP before booking for Arthrosamid® injection. This is to ensure you are safely able to take the prophylactic antibiotics required prior to the Arthrosamid® injection.

Have you ever had an allergic reaction to antibiotic medication?*

Yes

No

Allergic reaction to antibiotic? Please indicate any medical advice given to avoid this from happening in future

Do you have liver disease?*

Yes

No

Please give some medical detail if available

Do you have kidney disease?*

Yes

No

Please give some medical detail if available

Do you have cardiac arrythmias?*

Yes

No

Please give some medical detail if available

Do you have a history of clostridioides difficile infection (aka CDI or C Diff)?*

Yes

No

Please give some medical detail if available

Are you on Warfarin?*

Yes

No

What is your target INR? This should not be higher then 2.5

Do you have a history of ulcerative colitis?*

Yes

No

Do you take any blood thinning medication?*

Yes

No

What blood thinning medication do you take?

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

Yes

No

Please give some medical detail if available

Do you have any drug allergies?*

Yes

No

Drug Allergies

Could you currently be pregnant?*

Yes

No

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

Do you have any other medical conditions?

Yes

No

Medical conditions

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

Yes

No

Please give some medical detail if available

Please upload letters or reports here

Allowed formats: jpeg, png, pdf, doc, docx

Declarations

Please read the following declarations and confirm you have read and agree with each one by checking the box for each: (agreeing with the declarations by ticking the boxes

My GP is aware of and/or supports the need for / has referred me for ultrasound guided Arthrosamid injection (please note that this is not necessarry. It is at your personal discretion)

Other treatments have been tried and/or are not effective.

The risks and benefits for receiving an Arthrosamid injection have been considered and discussed with my GP / relevant health care professional. (please note that this is advisable but not necessarry. It is at your personal discretion)

Please read the Arthrosamid Injection Patient Information Leaflet before submitting this consent form

two arthrosamid boxes on top of each other

Can you please confirm that you have read the Arthrosamid Patient Information injection leaflet ? (below on this page)*

Yes

No

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

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

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