OBSTETRICS - GYNECOLOGY - INFERTILITY
15151 NATIONAL AVENUE - LOS GATOS, CA - PHONE:(408) 356-0431

I authorize Dr. ____________________ and those other persons, chosen by him or her or by the hospital or medical facility, to perform an operation called a Hysterectomy. A hysterectomy is an operation where the uterus is surgically removed. The uterus, or womb, is the organ that holds a baby when a person is pregnant and is involved with menstruation or the monthly period. If my uterus is removed, I will never be able to have any children, and my monthly periods will stop.

MY PHYSICIAN HAS DISCUSSED THE FOLLOWING WITH ME:

• HYSTERECTOMY IRREVERSIBLE. I am satisfied with my understanding that the hysterectomy operation is permanent and its effects can not be reversed.
• DIAGNOSIS. I am satisfied with my understanding of the reason(s) for the hysterectomy operation. I understand my diagnosis is:
  ______________________________________________________________________
• GENERAL RISKS AND COMPLICATIONS. I am satisfied with my understanding of the more common risks and complications which are described generally on the back of this form and include infection, bleeding, pain, anesthesia risks and death. Please initial when you have read and understand the risks on the reverse side ___________
• LENGTH OF HOSPITALIZATION. My doctor has informed me that my approximate length of hospital stay is 3 days, assuming no unforeseen complications.
• LENGTH OF RECOVERY. My doctor has informed me that my approximate length of recovery is 30-35 days, assuming no unforeseen complications.
• ALTERNATE METHODS OF TREATMENT. I am satisfied with my understanding of alternative procedures or treatments and their possible benefits and risks.
• ANESTHESIA. I understand that I will probably receive a general anesthetic. I understand the anesthesiologist will select and administer my anesthetic. I understand I should discuss with them the risks and benefits associated with the anesthesia they select,
• NO TREATMENT. I am satisfied with my understanding of the possible consequences, outcomes or risks if no treatment is rendered.
• SECOND OPINION. I have been offered the opportunity to seek a second opinion concerning the need for my hysterectomy.
• ADDITIONAL OR DIFFERENT PROCEDURES DURING CARE AND TREATMENT. I understand that unforeseen conditions may arise and that it may be necessary to perform operations and procedures different from, or in addition to, the hysterectomy described. I authorize and consent to the performance of such additional or different operations and procedures as are considered necessary and advisable. Such additional surgery may include removal of both tubes and ovaries. This would mean I would go through menopause and the risks and benefits of replacement estrogen therapy have been discussed with me.
• FREE TO WITHHOLD OR WITHDRAW CONSENT. I understand that I am free to withhold or withdraw my consent at any time before the hysterectomy without affecting the right to future care or treatment and without loss or withdrawal of any state or federally funded program benefits to which I might be otherwise entitled.
• NO GUARANTEES. I understand there are risks involved in any procedure or treatment, and it is not possible to guarantee, warrant or in any way to give assurance of a successful result.
• OTHER QUESTIONS. I am satisfied with my understanding of the nature of the procedure and all of my questions about the procedure have been answered.

I have read and been given a copy of this form.

Date______________ Patient Signature:______________________________________________________

Physician: _____________________________________________________

Medicine and surgery are generally safe, helpful and often lifesaving. However, medical or surgical proce- dures of any type involve the taking of risks, ranging from minor to serious (including the risk of death). It is important to be aware of the following possible risks before receiving the treatment you and your physician are planning. The following may be the reactions of your body to medical/surgical operations or procedures:

• INFECTION: Invasion of tissue by bacteria or other germs occurs to some degree whenever a cut, incision or puncture is made. In most instances, through the natural defense mechanisms of the body, healing of the affected area occurs without difficulty. In some instances antibiotic medicines are prescribed and at times additional surgical measures may be necessary to combat infection.

• HEMORRHAGE: The cutting of blood vessels causes bleeding and this occurs in every surgical incision. This bleeding is usually controlled without difficulty. At times, blood transfusions are required to replace blood loss. If blood transfusions are given, there are additional risks of liver inflammation, hepatitis, and the possibility of receiving Acquired Immune Deficiency Syndrome (AIDS). There is no absolutely reliable way to predict these unwanted reactions, some of which may be quite serious and even lead to death.

• DRUG REACTIONS: Unexpected allergies, lack of proper response to medications or illness caused by the prescribed drugs are possibilities. It is important for you to inform your physician and your anesthesiologist or certified registered nurse anesthetist of any problem you or your family have had with reactions to drugs and which medications you have taken in the past six months, including over-the-counter drugs, especially aspirin.

• ANESTHESIA REACTIONS: There may be unusual or unexpected responses to the gases, drugs or methods used to anesthetize you which can lead to difficulties with lung, heart or nerve function. Eating or drinking before anesthesia increases the risks of vomiting which may cause significant complications. Inform your anesthesiologist of problems you and your family have had with anesthesia.

• BLOOD VESSEL INFLAMMATION AND CLOTTING: It is impossible to predict the occurrence of blood vessel inflammation and clotting problems. If blood clots form, they can move from where they formed to other areas of the body and cause injury.

• INJURY TO OTHER ORGANS: Because of the closeness of other organs to the area being operated on, there may be injury to other organs. The stress of surgery or the procedure may also harm other organ systems of the body.

• OTHER RISKS: It is not possible to list all the possible risks and complications, and their variations, that may arise in any surgical operation or medical procedure. Each situation depends upon the purpose and nature of the operation or procedures. Your physician is willing to discuss further with you various details about other risks.

ALTERNATIVES TO TREATMENT

Although you and your doctor have decided upon this procedure, do not hesitate to discuss the reasons for the choice and the alternatives available for treatment of your condition. In addition, be sure to ask your doctor other questions that you may have about your treatment.