Injection & Ultrasound Enquiry Form

Full Name

Phone Number

Address

Age

Have you attended Life Fit Wellness before?

Yes No

If you know or think you know your diagnosis please provide details:

Do you think you require an injection or an ultrasound scan?

Injection Ultrasound Both

If you are considering an injection, what type of injection procedure do you think you may require?

Steroid / cortisone Hyaluronic acid / Hyaluronan / Lubricating Injection Cingal (combined steroid and hyaluronic acid - knee only) Hydrodistension for Frozen Shoulder High Volume Tendon Stripping Prolotherapy Injection Not sure Not applicable, scan only

Have you had a previous injection and if so please provide details of which region of the body was injected (i.e. knee, shoulder etc), what was injected (i.e. cortisone/steroid, hyaluronic acid), how many injections you have had in total and when the last injection was?

Do you have a blood clotting disorder?

Yes No

Do you take blood thinning medication (anticoagulants/antiplatelets )?

Yes No

If yes, please state which medication you take

Do you currently have an infection of any nature?

Yes No

Are you diabetic?

Yes No

Do you have a condition affecting your immune system?

Yes No

Are you pregnant?

Yes No

Do you have or have you had any other medical or health conditions? (Please provide details)

Please use this space to ask any questions you may have or provide any further information you think may be helpful.

I hereby agree to Life Fit Wellness contacting me in relation to the above enquiry

I agree

Injection & Ultrasound Enquiry Form

Please complete this form if you are interested in a diagnostic ultrasound scan or a joint or soft tissue injection. The questions are designed to assist in determining your suitability for injection. Once we have reviewed your answers we will be in touch.

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Opening Hours

Mon	8:00am - 7:30pm
Tue	8:00am - 4:30pm
Wed	8:00am - 7:30pm
Thu	8:00am - 7:30pm
Fri	8:00am - 4:00pm
Sat	9:00am - 1:00pm
Sun	Closed