CONSULTATION FORM

INFORMED CONSENT FOR HAYFEVER TREATMENT

This informed consent form is to provide written information regarding the risks, benefits, and alternatives of the procedure you are about to undertake. This material serves as a supplement to the discussion you have with your doctor/healthcare/medical provider. It is important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your doctor/healthcare professional prior to signing the consent form.

ABOUT THE PROCEDURE

Hayfever (seasonal allergic rhinitis) is a common allergic reaction to airborne allergens such as pollen. Symptoms may include sneezing, runny or blocked nose, itchy eyes, and difficulty breathing. Treatment options may include prescribed medications such as antihistamines, nasal sprays, and corticosteroid injections like Kenalog to help manage symptoms.

1. Oral Antihistamines – These help block histamine, the substance responsible for allergic reactions, and can help reduce sneezing, runny nose, and itching.

2. Nasal Sprays – Corticosteroid nasal sprays reduce inflammation in the nasal passages, improving breathing and reducing congestion.

3. Kenalog Injection (Triamcinolone Acetonide) – This is a corticosteroid injection designed to reduce inflammation and suppress the immune system’s response to allergens. It is often used when other treatments have failed or for those who experience severe hayfever symptoms.

   
   

KENALOG INJECTION – HOW IT WORKS

Kenalog (Triamcinolone Acetonide) is a long-acting corticosteroid that is injected intramuscularly (into the muscle). It works by reducing inflammation throughout the body, which helps minimise allergic reactions triggered by pollen and other allergens. This treatment can provide relief for weeks or even months by dampening the immune system's overactive response.

Pros of Kenalog Injections

• Long-lasting relief – Effects can last up to 8-12 weeks or more, helping reduce reliance on daily medications.

• Single-dose treatment – Suitable for individuals who do not respond well to antihistamines or nasal sprays.

• Convenience – No need for daily medication; a single injection can cover an entire hayfever season.

Cons of Kenalog Injections

• Cannot be reversed – Once administered, the effects of Kenalog cannot be undone.

• Not a cure – It provides symptom relief but does not eliminate hayfever.

• Potential side effects – Due to its systemic effect, it may cause hormonal changes, weight gain, or suppression of the immune system in some individuals.

• Not suitable for everyone – Those with diabetes, high blood pressure, or certain immune conditions may not be eligible.

  
  

RISKS AND COMPLICATIONS

While Kenalog is effective for many, it carries potential risks and side effects, including but not limited to:

Common Side Effects:

1. Temporary pain or swelling at the injection site.

2. Mild flushing or redness.

3. Temporary changes in mood or sleep patterns.

   
   

Less Common but Serious Risks:

1. Immune system suppression – Higher risk of infections.

2. Adrenal suppression – Prolonged use can reduce the body's natural ability to produce corticosteroids.

3. Osteoporosis (bone thinning) – Long-term corticosteroid use can weaken bones.

4. Weight gain and fluid retention – Some individuals may experience puffiness or bloating.

5. Changes in skin appearance – May cause skin thinning or lightening at the injection site.

6. Glucose imbalance – Can affect blood sugar levels, particularly in diabetics.

7. Hormonal effects – Menstrual irregularities, acne, or mood changes may occur.

   
   

   PUBLICITY MATERIALS

   I authorise the taking of clinical photographs and videos. I understand that photographs and videos may be taken of me for educational and marketing purposes. I hold the practitioner harmless for any liability resulting from this production. I waive my rights to any royalties, fees, and to inspect the finished production as well as advertising materials in conjunction with these photographs

   
   

RESULTS

Hayfever treatments, including Kenalog injections, can be highly effective in managing symptoms, but results vary from person to person. Kenalog does not permanently cure hayfever, and its effectiveness can differ based on individual response. If symptoms persist or return, alternative treatments or repeat doses may be necessary

POST-TREATMENT CARE

I have been instructed in and understand the post-treatment care instructions. I understand that:

• Sun protection is recommended as corticosteroids can make the skin more sensitive.

• I should monitor for any adverse reactions such as excessive swelling, infections, or significant changes in mood or weight.

• I should inform my healthcare provider if I develop any unusual symptoms after treatment

  
  

  RIGHT TO DISCONTINUE TREATMENT

  I understand that I have the right to decline or discontinue treatment at any time. However, once the Kenalog injection has been administered, it cannot be reversed. I acknowledge that payment for any treatments administered will still be required in full.

  
  

  PAYMENT

  I understand that this is an elective procedure and that payment is my responsibility and is expected at the time of treatment. I understand that this is a non-essential procedure and the procedure has been fully explained to me.

  
  

CERTIFICATION

I certify by signing this form that I have read and understood the information provided in this document. All of my questions have been answered satisfactorily. I accept the risks and complications of the procedure, and I understand that no guarantees are implied regarding the outcome. I also confirm that I will notify my healthcare provider of any changes in my medical history. I certify that I can read and write in English.

Personal Data

By Clicking submit you are confirming that the information provided is to the best of your knowledge true and accurate. Any information that is not disclosed may affect the decision the clinician makes, and may affect your health. In the instance of withheld information the clinician is not responsible for any adverse effects of treatment