PRP Intra-Articular Form

Platelet Rich Plasma Intra-Articular Therapy

Please complete the form below with your detailed information. If you prefer to print this form and bring it to your appointment, you may download it here.

PRP Intra-Articular Therapy Information

Name *

First

Middle

Last

Birth Date (MM/DD/YY) *

Site Being Treated *

Please specify right or left side of joint

Sex

Male
Female

Details Regarding Pain (Frequency, Cause of Pain etc.)

How severe is your pain on a scale of 1-10 (1 being no pain, 10 being worst pain of your life.)

Selected Value: 1

If you are having a joint injection, do you have any history of:

Osteoarthritis
Gout
Pseudogout
Rheumatoid Arthritis
Spondyloarthropathy
Other

If "Other" Describe

Prior Injections / Procedures / Surgeries on the site being treated?

Any histoy of low platelet count? (Thrombocytopenia)

If "Yes" Explain

Any personal history of cancer?

If "Yes" Explain

Do you have any allergies?

If "Yes" Please List

Are you taking any medications for pain management?

If "Yes" Please List

Are you taking any anticoagulants?

If "Yes" Please List

Any chance you could be pregnant?

Comment

This form meets HIPAA requirements for privacy.

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TWO CONVENIENT LOCATIONS

Oregon Imaging Centers at RiverBend Pavilion
3377 RiverBend Dr., Suite 150
Springfield, OR 97477

Hours:
M-F: 7:00 AM - 6:00 PM
(With extended hours for certain scheduled patients.)

Oregon Imaging Centers at University District
1200 Hilyard St., Suite 330
Eugene, OR 97401

Hours:
M-F: 6:30 AM - 9 PM
Sat & Sun: Open for scheduled appts. only
Walk-In X-rays available from 7:30-5:30 M-F