Prolotherapy Informed Consent Form

I have been advised and consulted about the injection technique of Prolotherapy/Prolozone/Ozone. I understand the risks involved and that no guarantees as to results are to be assumed, and none to be implied from these types of therapies. The technique requires the injection of local anesthetic (Procaine, Marcaine, and/or Lidocaine), 25-50% Dextrose (sugar water), methylcobalamin (vitamin B12), ozone, and other solutions. The sight of the injection is where the ligament or tendon attaches to the bone, at the joint capsule, a trigger point, and/or inside the joint.

I understand the possible BENEFITS of the procedure are to improve or resolve pain and improve function. The procedures may initially increase pain in the area or worsen symptoms for one to three days and then decrease pain and symptoms but may not completely eradicate them. I understand that this treatment may not be covered by my insurance due to some insurance companies considering this treatment to be experimental and that I am responsible for the total charge of the treatment. I understand that healing does not always proceed in a predictable manner and may take many weeks or months to experience full effect.

I have been informed of that the ALTERNATIVES to Prolotherapy include:

  • Do Nothing

  • Steroid Injections

  • Surgical Intervention

  • Manipulation

  • Acupuncture

I have been informed that the RISKS and COMPLICATIONS of Prolotherapy include:

  • Immediate pain at the Injection Site

  • Bruising Allergic reaction to the solution

  • Itching at the injection site(s)

  • Stiffness in the injected joint

  • Swelling after joint injections

  • Injury to the nerve and/or muscle

  • Temporary or permanent nerve paralysis

  • Lung puncture or collapsed lung

  • Dizziness or fainting

  • Bleeding Spinal cord injury from back injections

  • Headache from back injections

  • Infection from the injection

  • Nausea/Vomiting

  • Death due to complications of the treatment

  • Temporary blood sugar increase

  • Treatment may be ineffective

I have been informed that the risks of NO Prolotherapy include:

  • No pain relief

  • Continued instability of damaged joint or ligament(s)

  • Worsening of painful condition or symptoms

I certify that I have read and fully understand the above consent form and that any questions have been answered to my satisfaction. I hereby authorize Joint Repair Clinic of MT to perform the recommended procedure. I understand that because treatment usually requires a series of injections, the same risks, as described above, will also apply to those subsequent treatments.