Consent Form for Dilation and Curettage (D&C)

Name:                                                          

Resident Registration Number:                                  

Address:                                                       

I hereby request a dilation and curettage (D&C) procedure due to personal reasons.

I have discussed this decision with my guardian (                         ) 

and have agreed to proceed with the surgery.

Date of Signature:                              

Applicant:                              (Signature)

Guardian’s Name:                       (Signature)

Guardian’s Resident Registration Number:              

Guardian’s Phone Number:                            

To: Director of WOOLEE Obstetrics & Gynecology Clinic  

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.

PATIENT CONDITION / MEDICAL HISTORY

Past Medical History  Allergies 

Constitutional abnormalities  Diabetes mellitus 

Hypertension/Hypotension  Respiratory Disease 

Heart Disease  Thyroid Disease 

Liver Disease  Bleeding Tendency 

Kidney Disease  Smoking 

Cerebrovascular disease  CurrentMedications 

Drug Side Effects  Other 

 

1. Method and Details of the Procedure

1. When you arrive in the operating room, preparation will be done and conscious sedation (sleep sedation anesthesia) will be administered.

2. A speculum is inserted into the vagina and the vaginal canal is disinfected.

3. The cervix is grasped with a clamp, and the length and direction of the uterus are assessed (ultrasound may be used if needed).

4. The cervix is dilated sufficiently using surgical instruments to allow safe access.

5. Uterine contents are removed using a suction device.

6. After the procedure, ultrasound is performed to confirm whether any residual tissue remains in the uterus.

□ 7) If necessary, removed tissue will be sent for pathological examination.

(Please check this box if pathology is to be performed.)

2.Possible complications 

or Side Effects

1. Incomplete evacuation:

Even if an immediate postoperative ultrasound appears normal, a small amount of tissue may remain in areas not reachable by the suction device. In such cases, follow-up ultrasound performed days later may reveal retained products, requiring repeat surgery.

2. Inability to perform the procedure:

Rarely, severe cervical adhesions or an excessively curved uterine cavity may make the procedure technically impossible or incomplete.

3.Organ injury:

In rare cases, uterine perforation may occur, especially if the uterine wall is thin or the cavity is sharply angled. Intestinal injury may also occur.

Removing attached tissue with suction may stimulate and damage the endometrium, resulting in decreased menstrual flow; repeated curettage may lead to very light or absent menstruation.

4. Other adverse effects:

① Infection:

If inflammation is already present or bacteria enter the uterus during the procedure, endometritis or pelvic inflammatory disease may occur. Antibiotics are given postoperatively, but hospitalization may be required depending on severity.

② Intrauterine adhesions (Asherman’s syndrome):

Stimulated endometrium may adhere internally. Adhesion-preventing agents are used as preventive measures.

③ Hemorrhage:

As D&C is performed without direct visualization of the surgical field, unexpected bleeding may occur if instruments stimulate fragile tissue. In cases of severe hemorrhage, blood transfusion or additional interventions (hemostatic surgery or uterine artery procedures) may be required. This is a very rare complication.

Conscious sedation anesthesia (sleep anesthesia)

1. The need for conscious sedation anesthesia

Conscious sedation is used to reduce anxiety and discomfort by inducing a relaxed or sleep-like state during the procedure.

2. Method and Process of Sedation

1. After entering the operating room, preparation is completed and a monitoring device (pulse oximeter) is placed to check oxygen levels and heart rate.

2. Once the patient’s condition is confirmed stable, a sedative medication is administered intravenously.

3. Throughout the procedure, monitoring continues. If the procedure is prolonged, additional doses may be administered.

3. Possible Complications or Side Effects of Sedation

1. Inadequate sedation:

Some individuals may not reach sufficient sleep or sedation despite appropriate dosing, and may feel discomfort or pain. In such cases, additional analgesics may be given.

2. Adverse reactions:

Respiratory complications such as breathing difficulty or low oxygen levels, and cardiovascular effects such as tachycardia.

3. Very rare complications:

Respiratory arrest, cardiac arrest, or severe allergic drug reactions.

4. Patient Responsibilities Before and After Sedation

A. Before Sedation

1. Fasting: at least 4 hours prior to procedure.

2. Patients with chronic medical conditions must accurately inform medical staff.

3. Decisions about continuation or discontinuation of regularly taken medications must follow medical advice.

B. After Sedation / During Recovery

1. Discharge only after full recovery. Sedative effects may persist for some time.

2. Avoid driving or tasks requiring concentration for the remainder of the day.

3. You must be accompanied by a guardian to prevent safety accidents during discharge.

PATIENT CONSENT STATEMENT

I (or my representative) have received a full explanation from my attending physician about my current condition, the need for surgery, the surgical method, possible complications, anesthesia risks, and necessary postoperative care. I had the opportunity to ask additional questions freely, and I understand that unexpected or unavoidable complications may occur due to individual differences. I hereby consent to the surgery and anesthesia as explained and entrust my treatment to the attending physician.

Patien Name:                                                                 (Signature)

Date of Birth Contact (Mobile)

Guardian or Legal Representative                                   (Signature)

ADDITIONAL CONSENT CONDITIONS If the patient is unable to sign, please check the appropriate box below:

 Minor (under 19 years old) and unable to fully understand the content.

 Physically or mentally unable to comprehend consent information.

 Explaining the consent content may cause serious harm to patient’s mental or physical state.

 Patient has delegated consent authority to another person (attach authorization letter).

 Emergency situation where obtaining patient consent is difficult.

 Other:                     

Consent for Collection of Personal Information (for guardian/representative identification)

Date if Birth      .      .     . Sex M   /    F

Phone TEL Mobile

Address

Relationship Name                                 (Signature)

To: Director of WOOLEE Obstetrics & Gynecology Clinic