EOF-002 · Informed Consent Form
Intramuscular Therapeutic Injections
Trigger point · Neural therapy · Intra-articular cortisone · Botulinum toxin · Prolotherapy
Dr. Özgür Akşan — Neurosurgery (Brain and Nerve Surgery)
Intramuscular Therapeutic Injections — full text— 1. Dear Patient
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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.
CONSENT FOR INTRAMUSCULAR THERAPEUTIC INJECTIONS
Informed Consent Document
Trigger point · Neural therapy · Intra-articular cortisone · Botulinum toxin · Prolotherapy
| PATIENT PROTOCOL NO | DATE |
|---|---|
| TURKISH ID (T.C. KİMLİK) / PASSPORT NO | DATE OF BIRTH |
| PATIENT'S FULL NAME | SEX |
| DIAGNOSIS | (wide single cell) |
| PHYSICIAN | Dr. Özgür Akşan |
1. Dear Patient,
Injection therapy has been recommended to you for the diagnosis and treatment of complaints such as pain, spasm, and restricted movement originating from the muscles, joints, nerves, and the surrounding soft tissues. This form summarizes what the procedure involves, its expected benefits, and its possible risks. Please read it completely and carefully; ask your physician about any points of doubt.
2. Method and Area of Application
Injection therapy (administering injections) is a frequently used and effective method in the diagnosis and treatment of complaints such as pain, numbness, loss of sensation/movement, swelling of the joints and muscles, fluid accumulation, and muscle spasms that arise in conditions such as systemic rheumatic diseases, local/general trauma, metabolic diseases, nerve and spinal cord injuries, and inflammatory diseases.
The procedure consists of injecting one or more of the following substances into the muscle, inside/around the joint, and into other soft tissues (tendon, trigger point, ganglion cyst, neuroma, bursa, fascia, subcutaneous tissue, etc.) by means of a syringe and needle:
- Local anesthetic (lidocaine, prilocaine, procaine — neural therapy)
- Cortisone / steroid (depot forms — intra-articular / intramuscular)
- Botulinum toxin type A (treatment of muscle spasm)
- Dextrose / physiological saline (prolotherapy)
- Phenol / alcohol (for special nerve blocks, in highly selected cases)
When necessary, imaging and assistive techniques such as ultrasound, electrical stimulator, and fluoroscopy (scopy) are used.
3. Expected Benefits
- Assists both diagnosis and treatment
- Halts the inflammatory process within the joint
- Relieves or completely eliminates complaints of pain and restricted movement
- Helps avoid unnecessary use of systemic medication (pills/syrup)
- Reduces or eliminates the need for other treatment methods
- If needed, a fluid sample can be taken for analysis during the same session
- Does not require a special environment such as an operating room — it is performed under clinic conditions
4. Alternatives
The following alternative methods may also be considered for the treatment of this condition:
- Medication therapy (oral / intramuscular pain relievers, NSAIDs, muscle relaxants)
- Physical therapy and exercise programs
- Algological treatment methods (advanced pain treatment)
- In some cases, a surgical approach
The alternatives and their advantages/disadvantages were explained to me in detail by my doctor.
5. Possible Risks and Complications
Common (usually temporary, minor)
- Increased pain, burning, stinging at the injection site
- Redness, mild swelling of the skin, temporary bruising
Rare
- Nausea, dizziness, temporary change in blood pressure, palpitations
- Temporary rise in blood sugar (with cortisone injections, especially in diabetic patients)
Very rare but important risks
- Cardiac rhythm disturbance, palpitations, fainting
- Injury to or rupture of a nerve / muscle / tendon, temporary or permanent loss of strength, sensory disturbance
- Bleeding (especially in those taking blood thinners)
- Allergic reaction — rash, shortness of breath, very rarely anaphylactic shock
- Infection — abscess at the injection site, very rarely regional inflammation
Risks are very rare when proper technique, sterile materials, and an experienced physician are present. In the event of a complication, medical intervention is performed at the clinic; if necessary, referral to a hospital / emergency department is arranged.
6. Important Reminders
- You must inform the doctor of your known drug allergies, chronic diseases, and medications you take regularly (especially blood thinners, cortisone, immunosuppressants)
- You must report if you are pregnant / breastfeeding (some substances are contraindicated)
- No injection is performed into an area with active infection
- With repeated cortisone injections, attention is paid to the annual dose limit (to prevent joint damage)
7. Patient-Specific Information
The patient writes in their own handwriting any allergies, chronic diseases, medications used, previous surgeries, etc. If there are none, writing "NONE" is sufficient.
8. Signatures
I have read this form carefully, I have been informed about THE INJECTION TO BE PERFORMED, my questions have been answered, and of my own free will I give permission for this procedure.
| Full Name | 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 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 lacking decision-making capacity, and in medical emergencies.
- This form is specific to today's therapeutic injection. Separate consent will be obtained for any other injection to be performed at a future date.
- For a simple intramuscular injection (an injection in the buttock, pain reliever, antibiotic, etc.), a separate form, EOF-001, is signed.
- For interventional pain treatments performed under operating room conditions, such as facet / transforaminal / epidural / nucleoplasty / RF / cryoplasty, form AOF-008 is signed.
- This form is printed in two copies; one is given to the patient, 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).