INFORMED CONSENT FOR INTRAMUSCULAR INJECTIONS
CONSENT FOR CARE
You approve, authorize Praesidium Diagnostics dba Sameday Health and AR Medical, and any employee working under the direction of the physician, to provide medical care, or to this patient for which you are the legal guardian. This medical care may include services and supplies related to your health (or the identified person) and may include (but not limited to) preventative, diagnostic, therapeutic, rehabilitative, maintenance, palliative care, counseling, assessment or review of physical or mental status/function of the body and the sale or dispensing of drugs, devices, equipment or other items required and in accordance with a prescription. This consent includes contact and discussion with other health care professionals for care and treatment.
You understand during the course of the proposed treatment(s), test(s), or examination(s) unforeseen conditions may arise which may necessitate additional treatment(s), test(s), or examination(s). You consent to the performance of additional treatment(s), test(s), or examination(s).
It is important that you read this information carefully and completely. Please read and acknowledge this form before receiving your injection today. Parental consent is required for minors. If someone is translating for you, they must read you the form and you must approve.
You have the right to be informed about potential risks, complications, and possible benefits involved so that you may make the decision whether or not to undergo the procedure. This Informed Consent Form is not meant to scare or alarm you; it is simply an effort to make you better informed so that you may give or withhold consent for the procedure. Intramuscular (or IM) injection involves the injection of a substance directly into a muscle. IM injections are used for particular forms of nutrients and that are administered in small amounts (1-3cc). Depending on the compounds injected, they may be absorbed fairly quickly or more gradually. Our medical staff will administer the IM injection into the deltoid muscle (shoulder)
Proper diagnosis and treatment of a medical condition requires a formal office visit with a medical physician. Thrombocytopenia (low platelet counts) and coagulopathy (bleeding tendency) are contraindications for intramuscular injections, as they may lead to bruising and/or excessive bleeding. A routine blood test is recommended at least yearly to assess proper organ function. While no adverse reactions have been known to occur with any of the shot ingredients administered by this office, there are risks and hazards related to the performance of any injection. These risks include pain, erythema (redness), local edema (swelling), bleeding, bruising, injection fibrosis (scar tissue formation), headache, lightheadedness, and allergic reaction. Immediate medical attention may be necessary if you have a significant adverse reaction. Adverse reactions requiring immediate attention include, but are not limited to, fever of 101oF, chills, redness, drainage, or swelling at the injection site.
You understand that a record of my treatment will be generated with each visit. We are committed to your privacy and all health care information provided to Sameday Health and affiliated companies will be protected. Any disclosures of PHI (protected health information) will therefore require authorization unless used in the following ways:
Quality improvement regarding Sameday Health
Health-related benefits and services referral
Any court-ordered requests or subpoenas
Any law or government mandates with an appropriate warrant
You understand the information provided on this form and agree to all therein. You understand that there is no implied or stated guarantee of success or effectiveness of any treatment. The procedures set forth above have been adequately explained to me by my provider. You understand that you are free to withdraw my consent and discontinue participation in their treatments at any time.
You understand that, except in emergencies, you must give 24 hours notice of intent to cancel or reschedule my appointment. You understand that you will incur the full fee for treatment, regardless of the amount of supply used due to wasted materials.