Facet Joint Injection Discharge Instructions Form
Please review and acknowledge your post-procedure instructions following your facet joint injection.
Patient Full Name
*
First Name
Last Name
Date of Procedure
*
-
Month
-
Day
Year
Date
Location of Injection
*
Please Select
Cervical (Neck)
Thoracic (Mid Back)
Lumbar (Lower Back)
Did you experience any immediate side effects after the procedure?
*
No
Mild soreness at injection site
Numbness or tingling
Headache
Other
Post-Procedure Activity Instructions (Please check all that apply)
*
Rest for the remainder of the day
Resume normal activities tomorrow
Avoid strenuous activity for 24 hours
Do not drive for 12 hours
Apply ice to the injection site if needed
Which symptoms should prompt you to call the clinic or seek emergency care?
*
Fever over 101°F (38.3°C)
Severe headache or neck stiffness
Loss of bladder or bowel control
Severe redness or swelling at injection site
Other concerning symptoms
Medication Instructions Provided
*
Yes, reviewed and understood
No medications prescribed
Follow-up Appointment Scheduled?
*
Yes
No
Preferred Contact Number for Follow-up
*
Please enter a valid phone number.
Format: (000) 000-0000.
Acknowledge and Submit
Should be Empty: