Patient Consent Information Forms
To Our Healthcare Colleagues:
These information sheets may be useful in your patient education process or in developing your own informed consent informational forms.
You are free to download and modify them. However, this information is only for your private use with your patients. RESALE IS PROHIBITED.
Each of the information sheets is representative of another physician’s judgments of what risks, benefits and alternatives are material and important to the particular procedure. These information sheets were developed in conjunction with the informed consent program of an out of state teaching hospital, so they may not meet the requirements for a signed informed consent in Washington State.
A Sample Informed Consent Form Template is available for your adaptation. This form was developed by Helen Johnson and modified by a team of individuals at Providence Health System in an attempt to develop an informed consent form at a basic reading level. Before using this or any other template, you should seek advice from your Risk Manager or malpractice company. For a small fee you may purchase an excellent consent manual which includes sample consent documents from the Washington State Hospital Association.
Providence Regional Medical Center Everett's (PRMCE) Consent Policy can serve as a guide as you develop consent related materials and consent related questions can be directed to the PRMCE Organizational Quality Department at 425-261-3927. The PRMCE Informed Consent Training Booklet is the basis for staff training at PRMCE and provides information about staff and physician roles in the consent process as well as the applicable state laws plus a list of procedures requiring informed consent at PRMCE. Finally, many excellent patient education materials are available through your specialty society or MedlinePlus.
Please remember that the PRMCE Surgical and Invasive Procedure Consent form must be signed at PRMCE for invasive procedures performed at PRMCE. The educational documents in this section are intended to supplement the physician’s educational process with the patient, but do not replace PRMCE’s need to document the patient’s procedural consent.
Signed,
Lawrence Schecter, M.D.
Chief Medical Officer
Kevin Clay, M.D.
Medical Staff President
Alphabetical listing of Consent Information Sheets
(Note: to search by keyword use Edit/Find or Crtl F)
Abdominal Perineal Resection
Adenoidectomy
Amputation of Extremity
Anal Sphincteroplasty
Anesthesia, Monitored
Angiography
Anoscopy, Adult
Anoscopy, Pediatric
Anterior Cervical Fusion
Apheresis Catheter Placement, Temporary
Argon Laser Trabeculoplasty
Arterial Line Placement
Arthroscopy/Arthroscopic Surgery
Atrial Overdrive Pacing
Bladder Medicine, Instillation of
Bone Marrow Aspiration Biopsy, Adult
Bone Marrow Aspiration Biopsy, Pediatric
Brain Tumor Removal, Adult
Breast Biopsy, Image-guided Core Needle
Breast Cyst Aspiration, Ultrasound Guided
Breast Cytology, ultrasound-Guided fine needle aspiration
Breast Ductography
Breast Reconstruction, Tissue Expander
Breast Reconstruction, TRAM
Bronchoscopy with or without Biopsy
Bronchoscopy-Flexible, Adult
Bronchoscopy-Flexible, Pediatric
Bronchoscopy-Rigid, Adult
Bronchoscopy-Rigid, Pediatric
Bursa Injections
Cardiac Catheter Ablation
Cardiac Catheterization
Cardiac Stress Testing
Cardioversion, dc
Cardioverter/Defibrillator (ICD), Biventricular Implantable
Carpal Tunnel Release
Cataract Extraction and Intraocular Lens Implantation
Catheter Tube Change
Cautery, electric
Central Venous Catheter, femoral
Cervical Cryotherapy
Chest Tube Placement
Cholecystectomy
Cholecystectomy, laparoscopic
Circumcision
Circumcision, neonatal
Closed Reduction of a Fracture
Colectomy (Revised)
Collagen Injections
Colonoscopy, Pediatric
Colonoscopy, Adult
Colporrhaphy
Colposcopy
Coronary Sinus Lead addition to an Existing Permanent Pacemaker or ICD System
Cystectomy, Radical
Cystoscopy
Dental and Maxillofacial Implants
Dental Biopsy
Dental Extractions
Dilatation (Performed as Adjunct to Endoscopy)
Drainage, Aspiration
Dupuytren’s Contracture, surgery
Ear Lavage
EGD, Pediatric
Electrophysiology (EP) Study
Endomyocardial Biopsy and Right Heart Catheterization
Endometrial Biopsy
Endoscopy, Capsule
Endoscopy Dilatation, Pediatric
Endotracheal Intubation, Pediatric
Extensor Tendon Repair
Femoral Popliteal Bypass
Extraocular Muscle Surgery (Strabismus)
Fine Needle Aspiration
Flexible Sigmoidoscopy, Pediatric
Gastrostomy Tube Placement
Hysterectomy, Abdominal
Hysterectomy, Vaginal
Hysteroscopy, Diagnostic
Inguinal Hernia Repair
Intense Pulse Light (IPL) Photorejuvenation
Intra-Uterine Device (IUD), insertion
Joint Aspiration, Adult
Joint Fusion
Joint Injection
Knee Ligament Repair Reconstruction
Laparoscopy, Diagnostic
Laparoscopy, Diagnostic Operative OBGYN
Liposuction Surgery (Suction-Assisted Lipectomy)
Lumbar Laminectomy
Lumbar Puncture
Lumbosacral Epidural Steroid Injection
Lumbosacral Spinal Fusion
Mastectomy
Melanoma Excision
Mohs Micrographic Surgery
Myelography
Needle Localization, presurgery image-guided
Nephrectomy, Donor
Nerve Blocks
Nissen Fundoplication, Laparoscopic
Nissen Fundoplication, Open
Orthognathic Surgery
Pacemaker Defibrilator Implants
Paracentesis
Pediatric Catheterization, i & o
PEJ-PEG Placement, Pediatric
Percutaneous Transluminal Coronary Angioplasty (PTCA)
Percutaneous Transthoracic Needle Biopsy with Image Guidance
Perirectal Abscess Incision And Drainage
Peripherally Inserted Central Catheter (PICC) Line
Phototherapy (UVA)
Phototherapy (UVB)
Plasma Exchange, Therapeutic
Portacath Placement
Prostatectomy, Radical
Punch Biopsy
Red Blood Cell Exchange, Therapeutic
Removal of Epidermoid (Sebaceous) Cysts
Rhinolaryngoscopy
Right Heart Catheterization
Sigmoidoscopy, Flexible
Sinus Surgery, Endoscopic
Skin Biopsy (Dermatology)
Skin Cancer, Surgical Removal
Skin Lesion / Mole Excision
Splenectomy, Laparoscopic
Splenectomy, Open
Steroid Injections
Third molar extraction
Thyroidectomy
Thoracentesis
TiltTest, Bradycardia/Hypotension
TMJ Arthrocentesis/Arthroscopy
Tonsillectomy
Tonsillectomy and Adenoidectomy
Tracheostomy, Percutaneous
TransEchocardiogram Consolidated
Trigger Point Injections
Tympanoplasty
Ultrasound, obstetrical
Ventricular Atrial Shunt Insertion
VentriculoPeritoneal Shunt Insertion
Vestibular Nerve Section