|
Injection
• • •
|
Joint(s) Injected
• • •
|
|
Ultrasound guided
|
|
|
Consent
|
Position
|
|
PRP Bilateral Knees
|
Blood Draw Location
|
|
Needle
|
|
|
Left Knee
|
|
|
Needle
|
Approach
|
|
Ultrasound guided
|
|
|
(-) Fluid Aspirated
|
Volume of Fluid Aspirated
|
|
(+) Aspirate Description
• • •
|
Fluid sent for analysis?
|
|
Umbilical Cord Blood (Left Knee)
|
Umbilical Cord Blood mL
|
|
Invitrx Serial#
|
|
|
Amnio (Left Knee)
|
Amnio mL
|
|
Surgenex SurForce Lot#
|
Surgenex SurForce Tissue ID#
|
|
PRP (Left Knee)
|
Blood mL
|
|
Blood Draw Location
|
Needle
|
|
PRP mL
|
Extraarticular PRP? mL injected
|
|
Comments
|
|
|
Right Knee
|
|
|
Needle
|
Approach
|
|
Ultrasound guided
|
|
|
(-) Fluid Aspirated
|
Volume of Fluid Aspirated
|
|
(+) Aspirate Description
• • •
|
Fluid sent for analysis?
|
|
Umbilical Cord Blood (Right Knee)
|
Umbilical Cord Blood mL
|
|
Invitrx Serial#
|
|
|
Amnio (Right Knee)
|
Amnio mL
|
|
Surgenex SurForce Lot#
|
Surgenex SurForce Tissue ID#
|
|
PRP (Right Knee)
|
Blood mL
|
|
Blood Draw Location
|
Needle
|
|
PRP mL
|
Extraarticular PRP? mL injected
• • •
|
|
Comments
|
|
|
Ending
|
|
