EOF-001 · Informed Consent Form
Intramuscular Injection
Injection into the buttock — simple intramuscular medication (pain reliever, NSAID, antibiotic, vitamin B, muscle relaxant)
Dr. Özgür Akşan — Neurosurgery (Brain and Nerve Surgery)
Intramuscular Injection — full text— 1. Procedure to Be Performed
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What Is a Consent (Informed Consent) Form? What Is It For?
A consent form (formally an informed consent form) is a document that informs you about a procedure or surgery recommended to you. It explains in plain language what the procedure is, its expected benefits, possible risks, and alternative treatments if any.
Its purpose is not to frighten you, but to enable you to make the decision about your health knowingly and willingly. Giving or withholding consent to a procedure is your most natural right.
- It ensures you receive sufficient and understandable information before the procedure.
- It lets you see the benefits and risks in advance and ask your questions.
- It safeguards your right to decide freely and to withdraw your consent at any time.
You can read the form on this page, listen to it, and download it. After reading the form and having your questions answered, you give your consent by signing it at the clinic.
This information was prepared by Dr. Özgür Akşan.
INTRAMUSCULAR (INTO-THE-MUSCLE) INJECTION CONSENT
Informed Consent Document
| PATIENT PROTOCOL NO | DATE |
|---|---|
| TURKISH ID (T.C. KİMLİK) / PASSPORT NO | DATE OF BIRTH |
| PATIENT'S NAME–SURNAME | SEX |
| PHYSICIAN | Dr. Özgür Akşan |
1. Procedure to Be Performed
My doctor has explained to me that a medication will be injected by needle into a muscle (the buttock or another muscle group). Medication to be given: ……………………………………… (pain reliever / NSAID / antibiotic / vitamin B / muscle relaxant / cortisone, etc.).
This procedure is performed in a clinic setting, under sterile conditions, by experienced healthcare personnel.
2. Matters About Which I Have Been Informed
- The name, dose, and purpose of the medication
- Possible side effects and the risk of allergy
- I have informed my doctor about my previous drug allergies / chronic illnesses
- That I have the right to withdraw from this injection
3. Possible Risks and Complications
- Very common (minor): Mild pain at the needle site, redness, hardness, temporary swelling
- Rare: Local bleeding / bruising, temporary irritation of a nerve/vessel, dizziness, temporary change in blood pressure
- Very rare: Allergic reaction (rash, shortness of breath, anaphylaxis), abscess / infection at the injection site, nerve injury
- Extremely rare: Severe allergic reaction (anaphylactic shock)
The likelihood of these risks occurring is very low; however, should they occur, all necessary medical intervention is carried out at the clinic, and if needed, I will be referred to an advanced care center.
4. Patient-Specific Condition
The patient writes, in their own handwriting, any allergies, medications used, chronic illnesses, etc. If there are none, writing "NONE" is sufficient.
5. Signatures
I have read this form, I have been informed about intramuscular injection, my questions have been answered, and I give my consent to this procedure of my own free will.
| Name – Surname | Signature | Date / Time | |
|---|---|---|---|
| Patient | |||
| Legal Representative / Relative <br>(Degree of relationship: ……………………) | |||
| Responsible Physician | Dr. Özgür Akşan |
Notes
- Consent is obtained from the patient themselves if over 18 years of age; from the patient and additionally from their legal representative if the patient is between 15 and 18 years of age; and from the legal representative in the case of an unconscious patient, a patient under 15 years of age who lacks decision-making capacity, and in medical emergencies.
- This form applies only to today's injection. Separate consent is obtained for any other injection to be performed at a future date.
- For therapeutic intramuscular injections (neural therapy, trigger point injection, intra-articular cortisone, botulinum toxin, etc.), form EOF-002 is signed.
- This form is printed in two copies; one is given to the patient, and the other is placed in the clinic file.
- This form has been prepared based on Nöroşirürjide Aydınlatılmış Rıza Formları [Informed Consent Forms in Neurosurgery] (2025, ISBN 978-605-4149-28-5), published by the Türk Nöroşirürji Derneği (Turkish Neurosurgical Society).