Oral Steroid Consent Form

The provider has reviewed with me the potential risks, side effects, alternatives, and complications of taking oral steroids (ie Medrol Dose Pack, Prednisone). We have also discussed the reasons for taking steroids, including the potential benefits, as well as alternative treatments in place of taking oral steroids. I understand that risks of taking oral steroids include (but are not limited to) the following:

• Elevated pressure in the eyes (glaucoma)
• Fluid retention, causing swelling in the eyes, face, hands, feet, legs
• Increased blood pressure, myocardial infarction, arrhythmias, cerebro-vascular disease
• Mood swings (from mild irritability to severe mania, depression, seizures, suicidal ideation)
• Weight gain, with fat deposits in your abdomen, face and the back of your neck
• Cataracts; vision problems; eye pain
• High blood sugar, which can trigger or worsen diabetes
• Increased risk of infections
• Loss of calcium from bones, which can lead to osteoporosis and fractures
• Avascular necrosis (cellular death of bone components due to interruption of blood supply)
• Menstrual irregularities
• Suppressed adrenal gland hormone production
• Thin skin, easy bruising and slower wound healing
• Gastro-intestinal ulcers, nausea, vomiting, stomach upset
• Muscle atrophy; joint or groin pain
• Insomnia

I understand and agree to the use of an oral steroid medication in the management of my condition. I also understand that I have other alternatives to the use of oral steroids. With this knowledge of the potential risks, benefits, alternatives, and complications, I request that the provider proceed with the prescription of oral steroids. I also acknowledge that the provider has reviewed the use of this medication with me in detail, and answered all of my questions on the subject of the use of this medication. I acknowledge that I have been given a copy of this form, and it is also posted on the web site – www.beckerent.com. I understand that should I experience a side effect I am to call the provider immediately or head to the nearest emergency room.