Informed Consent Order Form - Rheumatology

Patient Name: _____________________________________________________
Patient DOB: _____________________________________________________
Provider Name: _____________________________________________________

Please Obtain Informed Consent for the Following:

   Possible Only
Aspiration of Joint or Periarticular Structure (12142)
This procedure involves removal of fluid from a joint or periarticular structure. This may include a bursa or a cyst. A bursa is a closed...
Heel - Injection (13043)
This procedure involves injecting local anesthetic in combination with a steroid into the heel. A local anesthetic is a numbing medicine. A...
Joint - Injection of Corticosteroid (12554)
This procedure involves injecting a joint with corticosteroid. This is a medication used to treat inflammation. Your doctor will mark your...
Muscle - Trigger Point Injection (11729)
This procedure involves injecting a numbing medication into the trigger point in the muscle. Sometimes, a corticosteroid may also be injected. ...

Additional Notes (include Anatomical Side/Location if Applicable):

Order Form Accurate Until 11/2/2021