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1919 State St. # 340, New Albany, IN 47150
812-945-5233
CONSENT FOR IN-OFFICE ENDOMETRIAL ABLATION
You are currently scheduled for an endometrial ablation. This procedure is used to attempt to destroy the lining tissue of the uterus so it cannot re-grow. The procedure involves opening (dilatation) of your cervix, with a special device. A hysteroscope will then be inserted through the vagina and cervix into the uterus. The physician will then use electrical or thermal energy to burn away the uterine lining.
Most women are not able to become pregnant after an endometrial ablation. If you want to become pregnant you should not have the endometrial ablation as serious risks and complications could occur should you become pregnant. Although pregnancy is not likely after an endometrial ablation, permanent sterilization should be used due to the possibility of serious risks and complications.
RISKS OF SURGERY
As with any surgical procedure, complications may occur. These may include but are not limited to:
Complications from anesthesia
Infection
Damage to or perforation of internal organs such as the uterus, bowel, bladder and vagina
Bleeding or hemorrhage possibly requiring transfusion and/or hysterectomy
Postoperative complications and/or death
Deep venous thrombosis or pulmonary embolus (blood clots)
Consent
My physician has fully explained to me the nature and purpose of the operation or procedure, the risks involved, the prospects for success and possible alternative methods of treatment. No guarantee has been given to me by anyone as to the results that may be obtained. I understand that undergoing any operation or procedure exposes me to an increased risk for infection which may result in a serious medical complication and/or death.
I consent to the performance of such additional operations and procedures not now contemplated which my physician considers necessary or advisable in the course of this procedure.
I consent to the examination and disposal by Ob/Gyn Associates of Southern Indiana of pathological wastes such as tissue.
I realize procedures require the participation of assistants, nurses and other personnel. I consent to medical and technical procedures by such personnel. If my physician has approved a product representative to be present for consultation during my procedure, I consent to the representatives presence and consultation.
My physician has also discussed the nature, risks, benefits and alternatives of moderate sedation with me and has determined that I meet the criteria and am an appropriate candidate for moderate sedation.
_______________________________________________ __________________
Signature of Patient or Legal Representative Date
_______________________________________________ __________________
Print Patient Name and Date of Birth Date
__________________________________________ ________________________________________________ __________________
Signature of Witness Date
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