Medical Consent For Hysterectomy Form - Caring For Women (Page 2 of 2) in pdf

I understand that the hysterectomy is permanent and not reversible. I understand that I will not be able to become

pregnant or bear children. I understand that I have the right to seek a consultation from a second physician. I

understand that no warranty or guarantee has been made to me as to result or cure.

_____ (Initial here)

I understand that certain complications may result from the use of any anesthetic including respiratory problems,

drug reaction, paralysis, brain damage or even death. Other risks and hazards, which may result from the use of

general anesthetics, range from minor discomfort to injury to vocal cords, teeth or eyes. I understand that other risks

and hazards resulting from spinal or epidural anesthetics include headache and chronic pain. _____(Initial here)

RISKS OF SURGERY: Just as there may be risks and hazards in continuing my present condition without treatment, there

are also risks and hazards related to the performance of the surgical, medical, and/or diagnostic procedures planned for me.

These may include, but are not limited to:

- Complications of anesthesia;

- Infection possibly not responsive to antibiotics;

- Nerve injury resulting in loss of function or chronic pain;

- Bleeding or hemorrhage possibly requiring blood transfusion;

- Injury to ovary, fallopian tube, appendix, bladder, ureter, rectum, and/ or vagina requiring surgical repair/reoperation and

possible stent, nephrostomy, colostomy, and prolonged catheter drainage;

- Injury to the bowel and/or intestinal obstruction (immediate or delayed) which could lead to infection in the abdomen

and/or sepsis;

- Vaginal cuff dehiscence requiring additional surgery;

- Postoperative complications or death;

- Blood clots in veins or lungs;

- Chronic pain;

- Allergic reactions;

- Uncontrollable leakage of urine;

- Possible emotional changes including sexual responses;

- Unforeseen or unanticipated complications;

- Need to convert to an open procedure.

After your surgery, you should expect to experience pain for the first few days. Normal activities, including sexual activity,

can be resumed in about 6 weeks in most cases. Meanwhile, don’t put anything in the vagina unless directed to do so by your

physician. Light physical work may be increased slowly. If activity causes pain, discuss it with the nurse or doctor. If your

incision becomes red or infected, call the office and speak to the nurse or doctor.

My signature certifies that:

- This form has been fully explained to me;

- I have read this form or it has been read to me and I understand its contents;

- Any blank spaces on this form have been filled in;

- I understand the procedure, the possible complications and postoperative care.

- Alternative methods of treatment (if any) have been explained to me;

- I have informed the doctor of all known allergies and medications (prescription, over-the-counter, and herbal therapies) that

I am taking.

- I authorize Dr._____________________ and whomever she/he may designate to assist him/her to perform the

hysterectomy.

_____________________________________________ ______________________

Name of Physician Explaining Procedure

Date

_____________________________________________

______________________

Signature of Patient or Legal Representative

Date/Time

_____________________________________________

______________________

Printed Name and Signature of Witness

Date

Medical Consent For Hysterectomy Form - Caring For Women Page 2

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