Synvisc

Synvisc Injections

If you have never had viscosupplements previously, please first visit the Synvic site to help determine if Synvic is the correct choice for you. You should also download, print, and review the following .PDF files:

ViscosupplementFAQs.pdf

HYALGAN_patient_brochure.pdf

SynviscInformedConsent.pdf

SynviscPostInjectionInstructions.pdf

Please bring the signed Informed Consent form with you on the day of your first injection.

Once you have completed the following form, you will be advised by email that you can schedule your first appointment (New Med Concern) and then two 15 minute follow-up visits, each a week apart from the prior visit.

Patient First Name: Patient Last Name: Date of Birth:

Insurance ID Number: Group Number (if applicable):

Insurance Preauthorization Contacts - Telephone: Facsimile:

Date of your last set of injections (month/year): "I was with the same insurance company then":

Which Joint? Joint Location(s):

Please select one of the following:

I already called my insurance carrier and they will cover the service without further action on your part.

I called the insurance carrier, but they require that you call & complete a form that they must fax to you.

I called the insurance carrier, but they require that you fax a note expressing my need for this procedure.

I called the insurance carrier, but they require that your office call for verbal approval for this procedure to be covered.