PLACE LABEL HERE
OBSTETRICAL DILATION AND CURETTAGE
INFORMED CONSENT
PATIENT NAME: ___________________________________ DATE: _______ TIME: ________
The diagnosis requiring this procedure is:
 Excessive bleeding after delivery
 Retained products of conception.
 Fetal demise
 Significant fetal abnormalities
The nature of the procedure is: To enlarge the opening to the uterus and empty the uterine cavity.
The purpose of this procedure is: Remove any tissue remaining in the uterus.
This procedure involves the material risk of infection, allergic reaction, severe loss of blood, loss or loss of function
of any limb or organ, paralysis, paraplegia or quadriplegia, disfiguring scar, brain damage, cardiac arrest or death.
ADDITIONAL RISKS: In addition to the material risks listed above, there may be other potential risks involved in this
procedure including, but not limited, to the following:
 Possible perforation of the uterus (one of the instruments might go through the wall of the uterus) which may require
immediate surgery or other additional surgery that may include the removal of the uterus, fallopian tubes and/or
ovaries.
 Possible inability to get pregnant or carry a pregnancy to term.
 Possible injury to the cervix, uterus, fallopian tubes, bladder and/or bowel.
 Possible formation of blood clots or emboli that may travel to other parts of the body and cause stroke or death.
 Possible fistula formation (an opening between bowel, bladder, ureter, vagina and or skin) caused by an injury to the
bowel, bladder or ureter.
 Possible formation of adhesions and /or scar tissues that may require surgical correction in the future.
The likelihood of success of this procedure is:
 good  fair
 poor
THE PRACTICAL ALTERNATIVES TO THIS PROCEDURE ARE:
No intervention
If I choose not to have the above procedure, my prognosis (future medical condition) is:
__________________________________________________________________________________
I understand that during the course of the procedure described above, it may be necessary or appropriate to perform
additional procedures that 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 deem necessary or appropriate.
I consent to diagnostic studies, tests, x-ray examinations and any other treatment or courses of treatment relating to the
diagnosis or procedures described herein.
*2-18098*
2
FORM 2-18098 INITIATED 06/2001
Page 1 of
PLACE LABEL HERE
OBSTETRICAL DILATION AND CURETTAGE
INFORMED CONSENT
I consent to the use of sedation and/or anesthesia as planned by my treating physician. The risks, benefits and alternatives
of such sedation/anesthesia have been explained to me. I understand that specific risks of anesthesia/sedation include, but
are not limited to, changes in blood pressure, allergic reaction, difficulty breathing, cardiac or respiratory arrest, seizure,
coma and death.
I consent to the use of blood and blood products as deemed necessary, both during and after surgery for this hospitalization.
The risks of exposure to AIDS, hepatitis or other infectious diseases as well as the need for and available alternatives have
been explained to me. (Cross through if this does not apply)
I consent that any tissues, specimens, organs or limbs removed from my body in the course of any procedure may be tested
or retained for scientific or teaching purposes and then disposed of within the discretion of the physician, facility or other
health care provider.
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 procedure which has been explained.
I understand that the practice of medicine is not an exact science and that NO GUARANTEES OR ASSURANCES HAVE
BEEN MADE TO ME concerning the results of this procedure.
By signing this form, I acknowledge that the risks, benefits and alternatives to the above procedure have been
explained to me, that I have read or had this form read and/or explained to me in general terms, that I fully
understand its contents, 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, related to the procedure described herein.
I hereby voluntarily request and consent for Dr. ______________________, as my physician, and any other physician(s),
and such associates, assistants or other medical personnel involved in performing such procedure(s), to perform the
procedure(s) described or referred to herein. I further consent to the presence of device or supply manufacturer’s
representatives in the operating room as may be deemed appropriate by my physician.
Additional materials used, if any, during the informed consent process for this procedure include:
__________________________________________________________________________________
Witnessed by:
____________________________________
Responsible Physician
___________________________________
Person giving consent
Relationship to patient if not the patient:
___________________________________
Patient unable to sign because:
___________________________________
FORM 2-18098 INITIATED 06/2001
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PLACE LABEL HERE
OBSTETRICAL DILATION AND CURETTAGE
INFORMED CONSENT
FORM 2-18098 INITIATED 06/2001
Page 2 of 2