Procedure Consent Form

Patient______DOB ______

Procedure Consent Form

This is what you need done: (circle)

-open and drain an infection -shave off or punch out tissue for testing

-remove a toenail -examine the vagina and cervix

-a shot in a joint -take tissue from the uterus for testing

-withdraw fluid from a joint -take tissue from the cervix for testing

-sew up a cut or wound -use freezing to remove bad tissue

-cast or splint bones or a joint

You need this done to: (circle)

-find out what is wrong -repair a cut or wound

-hold broken bones together -remove pus from an abscess

-reduce pain - fix an ingrown toenail

-remove a mole or patch of skin that may become cancer

This is what to expect if you have this done (treatment goal).

______

Here are some ways to treat your problem.

______

Here are things that can happen if you have this done (risks).

bleeding pain

infection I may get a hole in______.

a scar The treatment may not help.

I am a member of my health care team. I have a part in deciding what treatment I will have. I will follow the directions for my care after treatment. I will keep my appointments. I understand that doing these things will help keep me from having problems after my treatment.

I understand the possible risks we talked about. My questions have been answered. No promises were made about the results if I have this done. No one has promised a cure.

I give my permission for Doctor/Nurse Practitioner/Nurse Midwife ______and any assistants to treat my problem that is circled above.

Patient______à ______

sign your name here print your name here

Guardian______à ______

sign your name here print your name here

Before the patient or his/her representative consented to have this procedure, I explained the procedure, including possible risks, complications, alternative treatments (including non treatments) and expected results. The patient or his/her representative verbalized an understanding of the information.

MD/CNP/CNM ______Date______Time______

Time Out: Patient IDx2:______Procedure to be done______

______

correct side marked______

Reading Health, a program of Project:LEARN, assisted in the writing of this material

under a grant from the St. Luke’s Foundation.

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Candafiles\literacy\taskforce\proc-consent.doc (2/08; rev’d 6/08)