PLACE LABEL HERE
Post Partum Tubal Ligation Informed Consent
PATIENT NAME: _____________________________________________
DATE: ____________TIME:____________
The diagnosis requiring this procedure is: Undesired fertility
The nature of the procedure is: To surgically obstruct (block) the fallopian tubes by laparoscopy (a small incision(s) is made in the
abdomen and the fallopian tubes are either “burned” by electrofulgoration or a clip or band is applied to the tubes) or by partial
salpingectomy where an abdominal or vaginal incision is made and part of each fallopian tube is removed.
The purpose of this procedure is: To attempt to make the person sterile (unable to become pregnant).
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:
 The procedure could fail and the patient could become pregnant.
 Possible injury to bowel, bladder, ureter or other pelvic or abdominal structures.
 Possible fistula formation (an opening between bowel, bladder, ureter, vagina and/or skin) caused by an injury to the bowel,
bladder or ureter.
 Possible need for immediate surgery or other additional surgery.
 Possible blood clots or emboli that might travel to other parts of the body and cause stroke or death.
 Increased risk of ectopic pregnancy if the patient becomes pregnant in the future.
 This procedure is NOT designed to be reversible and should be considered to be permanent.
The likelihood of success of this procedure is:
good
fair
poor
THE PRACTICAL ALTERNATIVES TO THIS PROCEDURE ARE:
Hormonal contraception (pills, shots or implants), intrauterine devices, rhythm method, barrier methods such as foams, diaphragms
and/or condoms, vasectomy (male sterilization), or abstinence.
If I choose not to have the above procedure, my prognosis (future medical condition) is:
That there is a greater possibility of continued fertility.
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.
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 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.
FORM #2-18097 REV. 01/2006
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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:
__________________________________________________________________________________
____________________________________
Signature of Person giving consent
________________________________________
Relationship to patient if not the patient
Patient unable to sign because:
________________________________________
Responsible Practitioner’s Statement:
I have reviewed that contents of this form, including the risks, benefits, and alternatives to the proposed procedure, with the patient or
the patient’s decision-maker, and have provided the patient/decision-maker with an opportunity to ask questions.
____________________________________
Responsible Practitioner
___________________________________
Date/Time
CONSENT UPDATE
I acknowledge an understanding of the above discussion and explanations. I have been given the opportunity to ask questions and
discuss that procedure during the update process. I request and consent to the performance of the procedure described or referred to
above.
___________________________________
Signature of Person giving consent
_______________________________________
Relationship to patient if not the patient
Patient unable to sign because:
_______________________________________
__________________________________
Witness
FORM #2-18097 REV. 01/2006
____________________________
Date/Time
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