Hysterectomy Consent Form printable pdf download

Hysterectomy Consent Form

1. This form is called an “informed consent form.” Its purpose is to inform me about the

hysterectomy procedure.

2. The following operation(s) will be performed on me:

_____________________________________________________________________________

3. I was told that hysterectomy means removal of the uterus (womb) either through an incision in

the lower abdomen and/or through the vagina. Sometimes additional surgery may be indicated to

remove or repair other organs such as the ovaries, tubes, appendix, bladder, rectum, and vagina.

4. I was told that the hysterectomy procedure is considered irreversible and that, unless I am already

sterile or postmenopausal, it will result in permanent infertility.

5. I have been told that this procedure may subject me to a variety of discomforts, risks and complications.

These include nausea, vomiting, pain, bleeding, infection, poor healing, hernia, or formation of

adhesions. Unexpected reaction may occur from any drug or anesthetic given. Unintended injury

may occur to other pelvic or abdominal structures such as the tubes, ovaries, bladder, ureter (tube

from kidney to bladder), or bowel. Nerves going from the pelvis to the legs may be injured. Any such

injury may require immediate or later additional surgery to correct the problem. Dangerous blood

clots may form in the legs or lungs. Physical and sexual activity will be restricted during the recovery

period. Finally, I understand that it is impossible to list every possible undesirable effect and that the

condition for which surgery is done is not always cured or significantly improved, and in rare cases

may even worsen.

6. I have been told that I can expect the following benefits from the proposed operation(s), but that

no results can be guaranteed:

_____________________________________________________________________________

7. I have been told that the following are alternatives to hysterectomy, and those that are checked may

apply to me:

Leave the problem untreated and accept the natural course of the condition.

Attempt to control some problems with hormones or other medications.

Attempt to control some problems with uterine artery embolization.

Remove just the diseased or abnormal tissue and repair the remainder.

Use mechanical devices for pelvic support.

Other: __________________________________________________________________

8. I have the right to consult a second physician before having the hysterectomy

9. I have the right to withdraw my consent to the hysterectomy at any time before it is performed.

My withdrawal of consent shall not affect my right to future care or treatment or result in the loss or

withdrawal of any state or federally funded program benefits to which I might otherwise be entitled.

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Hysterectomy Consent Form