Clinical Risk Assessment for Injection Therapy

Last Updated: 22/06/2021

Patient History

Please provide as much history as you can so the clinician can process your request

Have you experienced any of the following?

Do you have any of the following? (Contraindications to an injection)

Do you have any of the following?

Here is a list of common side effects. Please tick yes to imply you are aware of the potential side effects

You agree to the following instructions

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