PLACE LABEL HERE
PLACE LABEL HERE
SummitRidge
Form Name
DO NOT SIGN THIS FORM UNTIL YOU HAVE READ
IT AND FULLY UNDERSTAND IT’S CONTENTS!
PATIENT NAME: ______DATE: _____/_____/_____
Month Day Year
I acknowledge and understand that the following procedures have been described to me and are to be performed on the above named patient.
The following has been explained to me in general terms and I understand that:
The nature of the procedure is to surgically obstruct (block) the fallopian tubes. This can be done by several different methods, including:
a)laparoscopy (a small incision(s) is made in the abdomen and then the fallopian tubes are either “burned” by electrofulgoration or a clip or band is applied to the fallopian tubes);
b)partial salpingectomy (an abdominal or vaginal incision is made and part of the fallopian tubes are removed). This can be done along with a cesarean section without requiring an additional incision.
The purpose of this procedure is to attempt to make the patient sterile (unable to become pregnant).
I represent and warrant that I AM EITHER LAWFULLY MARRIED, or eighteen (18) years of age or over, and understand that the physician named above, other acting in collaboration with him, his assistants, and the hospital or establishment wherein the said operation is to be performed are acting in reliance upon my statements.
The operation has been explained to me, and I understand, that this operation is intended to result in sterility, although this result has not been guaranteed. I understand that a sterile person is NOT capable of becoming a natural parent.
MATERIAL RISKS OF THIS PROCEDURE:
As a result of this procedure being performed there may be material risks of; INFECTION, ALLERGIC REACTION, DISFIGURING SCAR, SEVERE LOSS OF BLOOD, LOSS OR LOSS OF FUNCTION OF ANY LIMB OR ORGAN, PARALYSIS OR PARTIAL PARALYSIS, PARAPLEGIA OR QUADRIPLEGIA, BRAIN DAMAGE, CARDIAC ARREST, OR DEATH.
In addition to these material risks, there may be other possible risks involved in this procedure including but not limited to:
- THE PROCEDURE COULD FAIL AND THE PATIENT COULD BECOME PREGNANT.
- Possible injury to bowel, bladder, ureter or other pelvic or abdominal structures;
- Possible fistula formation (an opening between bowel, bladder, ureter, vagina and/or skin) caused by an injury to the bowel, bladder or ureter;
- Possible need for immediate surgery or other additional surgery;
- Possible blood loss necessitating transfusion which carries the risk or exposure to AIDS, hepatitis or other infectious diseases;
- Possible emboli (clots of blood or other material) that might travel to other parts of the body;
- Possible formation of blood clots;
- This procedure is NOT designed to be reversible and should be considered to be permanent.
The likelihood of success of the above procedure is: (___) good; (____) fair; (____) poor.
If the patient chooses not to have the above procedure, the prognosis (predicted future medical condition) is that the patient may continue to be able to become pregnant.
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Practical alternatives to this procure include:
a. Birth Control Pills;e. Barrier methods such as foams, diaphragms, and/or condoms;
b. Intrauterine devices (IUD); f. Vasectomy (male sterilization);
c. Rhythm methodg. Abstinence;
d. Withdrawal method;h. No birth control at all.
I understand that the physician, medical personnel and other assistants will rely on statements about the patient, the patient’s medical history and other information in determining whether to perform the procedure or the course of treatment for the patient’s condition and in recommending the above procedure.
I understand that the practice of medicine is not an exact science and that NO GUARANTEE OR ASSURANCES HAVE BEEN MADE TO ME concerning the results of this procedure.
I understand that during the course of the procedure described above it may be necessary or appropriate to perform additional procedures which are unforeseen or not known to be needed at the time this consent is given. I consent to and authorize the persons described herein to make the decisions concerning such procedures. I also consent to and authorize the performance of such additional procedures as they seem necessary or appropriate. I also consent to diagnostic studies, tests, anesthesia, x-ray examinations and other treatment or courses of treatment relating to the diagnosis or procedures described herein.
BY SIGNING THIS FORM, I ACKNOWLEDGE THAT I HAVE READ OR HAD THIS FORM READ AND/OR EXPLAINED TO ME, THAT I FULLY UNDERSTAND ITS CONTENTS, AND THAT I HAVE BEEN GIVEN AMPLE OPPORTUNITY TO ASK QUESTIONS AND THAT ANY QUESTIONS HAVE BEEN ANSWERED SATISFACTORILY. ALL BLANKS OR STATEMENTS REQUIRING COMPLETION WERE FILLED IN AND ALL STATEMENTS I DO NOT APPROVE OF WERE STRICKEN BEFORE I SIGNED THIS FORM. I ALSO HAVE RECEIVED ADDITIONAL INFORMATION INCLUDING BUT NOT LIMITED TO THE MATERIALS LISTED BELOW RELATING TO THE PROCEDURE DESCRIBED HEREIN.
I voluntarily consent to allow Dr. ______or any physician designated or selected by him or her and all medical personnel under the direct supervision and control of such physician and all other personnel who may otherwise be involved in performing such procedures to perform the procedures described or otherwise referred to herein.
______
Witness(Person giving consent)
______
(Relationship to patient if not the patient)
______
(Patient unable to sign due to)
Additional materials used, if any, during the informed consent process for this procedure included: ______
I warrant that I am duly licensed without restriction to practice medicine and surgery in the State of Georgia pursuant to Chapter 84-9 or Chapter 84-12 of the Code of Georgia of 1933, as amended. I have examined (Patient) and
have agreed that said patient should be sterilized by the performance of the following operation:______
I have given a full and reasonable medical explanation as to the meaning and consequence of such operation to the said patient, and have explained to the said patient that the above stated operation, which has been requested and consented to has not been guaranteed. I believe that the said patient understands that a sterile person is not capable of becoming a natural parent.
The said patient has voluntarily requested the above described operation in writing and I believe that the said patient understands the nature of the operation, risks involved, and possibility of complications and that if the operation proves successful the results will be permanent and it will thereafter be impossible for the patient to inseminate or to conceive or to bear children.
I believe that the patient voluntarily requested the performance of the above described procedure, that the request is not the result of any force or coercion by any person, that the patient is either lawfully married, or the patient is eighteen years of age or older.
SIGNED: ______DATE: _____/______/______
Medical DirectorMonthDayYear
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