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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.
Email *
Full Name *
Address *
Phone number *
Have you attended Life Fit Wellness before? *
If you know or think you know your diagnosis please provide details: *
Do you think you require an injection or an ultrasound scan?
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In which body region do you think you may require an injection or scan? *
If you are considering an injection, what type of injection procedure do you think you may require? *
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? *
Do you take blood thinning medication (anticoagulants)? *
Do you currently have an infection of any nature? *
Are you diabetic? *
Do you have a condition affecting your immune system? *
Are you pregnant? *
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: *
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