Consent form for cervical hyperfrequency surgery
The following is the consent form required for the patient's surgery. After listening to the explanation, if you have any questions, please be sure to ask the medical staff who will explain and fill out the form.
|
Registration Number :
Patient Name :
Age: years old
|
Explainer:
Surgeon:
Diagnosis :
Surgery Name:
Date of surgery :
|
◈ Patient's condition or peculiarities
|
Calendar (Disease, Injury, History) |
□ |
|
allergy |
□ |
|
|
Idiosyncratic Constitution |
□ |
|
diabetes |
□ |
|
|
High / Low Blood Pressure |
□ |
|
Respiratory Diseases |
□ |
|
|
Heart disease |
□ |
|
Thyroid disease |
□ |
|
|
Liver disease |
□ |
|
Bleeding predisposition |
□ |
|
|
Kidney disease |
□ |
|
Smoking Status |
□ |
|
|
Cerebrovascular disease |
□ |
|
Medications you are taking |
□ |
|
|
Drug side effects |
□ |
|
guitar |
□ |
|
◈ Cervical hyperfrequency surgery
|
Description
|
|
|
1. Need for surgery
|
□(1) Cervical diathermy tomy: Necessary to remove the lesion of the cervix confirmed by biopsy and to make a final diagnosis by pathological examination of the removed tissue. □(2) Cervical radiofrequency coagulation : To treat chronic cervicitis and cervical bleeding |
|
2. Method and content of surgery
|
(1) When the patient arrives at the operating room, preoperative treatment and anesthesia will be administered. (2) The plantain is inserted into the vagina and disinfected. |
