Consent Form for Dilation & Curettage (Endometrial Biopsy) and Anesthesia
This is the consent form required for your procedure. After receiving explanations from the medical staff, please ask any questions you may have and complete the form.
uPATIENT CONDITION / MEDICAL HISTORY
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Past Medical History
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o
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Allergies
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o
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Constitutional abnormalities
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o
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Diabetes mellitus
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o
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Hypertension/Hypotension
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o
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Respiratory Disease
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o
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Heart Disease
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o
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Thyroid Disease
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o
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Liver Disease
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o
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Bleeding Tendency
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o
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Kidney Disease
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o
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Smoking
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o
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Cerebrovascular disease
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o
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CurrentMedications
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o
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Drug Side Effects
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o
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Other
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o
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Description
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1. Need for surgery
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□ To treat bleeding or pain caused by endometrial lesions and to assess for abnormal endometrial pathology. |
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2. Method and Details of the Procedure
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1.After arriving in the operating room, p |
