Risk Management

Patient Educational Materials and Consent Forms

The following documents combine educational material with a consent form. The first few pages of each document are for the patient to read and keep. The final page is a consent form for the patient to sign. These forms are written for patients undergoing minor procedures (those not requiring general anesthesia) or taking certain medications.

Here's how to use the forms:

1. Give the entire document to the patient to read before the procedure. The patient must have a reasonable amount of time to review the document. However, the material should not be given more than two weeks prior to the procedure; otherwise the patient's medical condition may change or the information provided may be forgotten.

2. Allow the patient a chance to discuss the procedure and ask any questions that he or she may have.

3. Have the patient sign and initial where appropriate on the final page of the form.

4. Keep the page with the patient's signature and initials in the patient's medical record.

5. Archive the educational material. Keep one copy in your education folder/files and write the date on the information. The material can be kept electronically or in paper form.

• Botulinum Toxin Type A (Botox)
• Clomiphene (Clomid)
• Elective Circumcision
• Lesion Removal with Local Anesthesia
• Loop Electrosurgical Excision Procedure (LEEP)
• Stereotactic Breast Biopsy
• Vaginal Delivery
• Warfarin (Coumadin)