[Click HERE for a printable PDF of this Consent form.]


I, ______________________________have been advised and it has been recommended by my physician, Dr. ______________, for me to receive treatment for __________________ in the form of Injection Therapy. In signing this form and based on the information that has been provided to me, I am consenting to and authorizing the procedures listed below, use of medications necessary to complete the treatment and such other treatment as may be related to and necessary for my physician to complete this treatment. I also understand that in some instances it may be necessary and I am consenting to a series of treatments that may last four to six months. I also agree that in addition to the information contained in this consent, I have been provided with an opportunity to discuss this treatment with my physician and his/her staff.


______ Neural Therapy

______ Trigger Point Injection

______ Prolotherapy

(Check applicable procedure)

A description of each specific procedure is attached to this form. The general benefits and risks are discussed below.

Benefits and Risks

Injection Therapies are a medically recognized set of procedures that are frequently utilized for conditions involving musculoskeletal injuries and longstanding pain and discomfort. In almost all cases, Injection Therapy is considered safe, minimally invasive with minimal risk of complications, and is done by a physician. I also understand that Injection Therapy MAY alter and decrease my pain complaints, but the treatment is not a guarantee from my physician that my pain will be completely eliminated.

In signing this form, I am agreeing that my physician has reviewed with me and I understand that possible alternatives to Injection Therapy are:

  1. Refuse treatment at this time.
  2. Surgical intervention.
  3. Steroid injection(epidural).
  4. Continued manual therapy.
  5. Alternative treatments (specify and initial) __________________________

In the absence of treatment I understand that my pain may continue without relief; and depending on my diagnosis, there may be additional musculoskeletal deterioration, or other symptoms such as persistent somatic dysfunction.

The general risks of Injection Therapy, depending on the actual procedure, may involve:

  1. Allergic Reactions (which if untreated could result in death)
  2. Pain at the injection site.
  3. Infection at the injection site.
  4. Loss of tissue mass with or without cosmetic changes.
  5. Pneumothorax (punctured lung) during injections around the rib cage.
  6. Temporary numbness or dizziness.

In the case of Prolotherapy, additional risks may include:

  1. Immediate pain at the injection site that may last 2 – 10 days.
  2. Spinal cord injury during certain back injections.
  3. Injury to nerves, muscles or blood vessels at the injection site.
  4. Temporary or permanent nerve injury most commonly manifested as tingling.
  5. There may be no effect from treatment.

Extreme caution will be taken by the doctor to minimize any and all of the aforementioned complications.





      Signature of patient (or person
with authority to consent for patient)







Witness to signature





For Persons Requesting Prolotherapy, a separate information booklet will be provided. Please acknowledge that you have received, read and have had an opportunity to ask any questions related to prolotherapy . ____________ (initial)

Because Prolotherapy is considered an ALTERNATIVE treatment, private insurance companies may not pay for prolotherapy, and MEDICARE WILL NOT PAY FOR ANY PROLOTHERAPY TREATMENTS. ___________ (initial)




Neural Therapy

Neural Therapy is a minimally invasive injection technique used by physicians to help patients with pain related to scars. It requires the injection of local anesthetic (Procaine or Lidocaine) into the scar tissue of the skin (old or new), but does not involve injections into any other parts of the body. The purpose is to decrease pain and binding associated with the scar tissue. Since the scar is often associated with a traumatic injury, it is not uncommon for patients during the procedure to have some recall as to the original trauma causing the injury. Since this may result in some temporary anxiety and/or apprehension regarding the procedure, you should make your physician aware of any concerns you may have so that he/she can discuss with you any additional interventions that may be of benefit. Typically scars will soften and “relax” over a series of treatments allowing for greater mobility as the scar is remodeled biophysically and mentally.

Trigger Point Injection

Trigger Point Injection is an injection technique frequently used to help patients with pain resulting from an acute muscle injury or from a variety of repetitive strain injuries. It has been in use for over 70 years. A portion of a muscle is tighter than the tissue around it, reducing the normal blood flow through that part of the muscle. This trigger point becomes tender, the muscle tires more easily, it ultimately becomes weaker, and it may cause significant radiating pain. This positive feedback loop between the spine and a group of receptors in a portion of the muscle can be thought of as a “glitch” in the software of the neural system that blocks the normal reparative process. By briefly interfering using the anesthetic properties of lidocaine, and the microinjury caused by the needle point, the normal reparative process can be jumpstarted. Occasionally, a steroid medication may be used for bursitis or certain inflammatory conditions.


Prolotherapy is an injection treatment designed to stimulate healing of ligament laxity and tendon weakness or joint instability. The painful weakened areas are injected with a proliferant solution which causes an intense inflammatory reaction. This reaction then initiates a new healing phase wherein cells called fibroblasts deposit new collagen over the subsequent weeks. The new collagen “lines up” along the functional lines of stress of the tendon or ligament so as to strengthen these tissues. Prolotherapy is helpful for pain problems due to ligamentous laxity that have not been resolved by more conservative treatment, such as manual therapy, trigger point injections, therapeutic exercise or medications. Ligamentous reconstruction involves more risk and discomfort for the patient, as well as more commitment to rehabilitation. Antinflammatories are counterproductive and opiates are used for pain control. Benefit may be seen in as little as 2-6 injection sessions. Patients with more extensive damage will require more treatment. MEDICARE WILL NOT COVER THE COST OF TREATMENT. In smokers, vegetarians and the immunosuppressed, healing may be less than optimal.