Consent for self-administration of injections

Consent for Self-Administration of Injections

Your First Names: *

Your Last Name: *

Your Date of Birth: *

Phone Number: *

I have chosen self-injection and I am aware of the alternatives.

I am able to keep medicine and equipment safe at home.

I am aware of the safety aspects of self-administering, including safe disposal of needles, vials and syringes.

I have received training, either face to face or by reading the information provided.

I have the necessary skills and knowledge to self-administer.

I am aware of monitoring requirements (if any).

I agree to administer the first injection during Health Centre opening hours and I know who to contact if I have any concerns.

I agree that I have read, understood and intend to follow the information given, in order to inject myself safely. *

Signature: *

Date: *

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