Patient: _________________________________________________

Date: ____________________

1. I hereby authorize Dr. _____________________________ to perform arthrocentesis or aspiration and injection of a joint. The joint is: _____________________________.

2. I understand that this is a procedure performed by placing a needle into the joint. The goal is to withdraw fluid from the joint to provide pain relief, analyze the fluid under the microscope, and, possibly, inject medication into the joint for additional relief. I understand that the removal of fluid may be needed to find out why the fluid was present. I understand that fluid may re-accumulate after the removal. I understand that the medication that may be injected is a corticosteroid and may not provide long-lasting relief. I understand that the practice of medicine is not an exact science, and that no guarantee can be made about the outcome of my planned procedure.

3. My doctor has explained to me that this procedure generally is safe, but that certain risks accompany any surgical procedure. Risks associated with joint aspiration and injection include the following:

   Pain associated with the procedure if the needle touches joint surfaces

   Injection into an artery or vein if the needle tip was misplaced

   Damage to a nerve or joint surface from the needle or medication

   Rare introduction of infection into the joint

   Increased joint pain after injection of medication, or postinjection flare reaction

   Rare, unusual reactions, including possible death, following any surgical procedure

4. I understand that there are alternate diagnostic and treatment options to this procedure. I understand that I can refuse this procedure.

5. I understand that unforeseen conditions may alter the planned procedure. I give permission to my doctor to alter the procedure (such as to remove extra fluid for laboratory study), if necessary, or to administer additional anesthetics or other medication if I should need them for the completion of my procedure.

6. I have read this form and other sheets given to me by my physician. I have had my questions answered to my satisfaction.

Witness: _______________________________  Patient: _______________________________

Date: _________________________________

Minor: _______________________________  Parent: _______________________________

Adapted with permission from Zuber TJ. Office procedures. Baltimore: Lippincott Williams & Wilkins, 1999.