Endocrine Treatment and Procedure Informed Consent

Patient Information

Name: _________________________ Date of Birth: _________________ Medical Record #: ______________

Procedure/Treatment Information

Nature of Procedure/Treatment

I, _________________, hereby authorize Dr. _________________ and associates to perform the following procedure(s)/treatment(s):

• Thyroid Fine Needle Aspiration
• Radioactive Iodine Treatment
• Insulin Pump Initiation
• Continuous Glucose Monitoring System Placement
• Other: _________________________

Explanation of Procedure/Treatment

The following has been explained to me in detail:

1. The nature and purpose of the procedure/treatment
2. The expected benefits
3. The possible risks and complications
4. Alternative treatment options
5. The consequences of not receiving treatment

Risks and Complications

I understand that specific risks include but are not limited to:

• Infection at the procedure site
• Bleeding or bruising
• Allergic reactions to medications or materials
• Treatment-specific risks as discussed: _________________________

Patient Acknowledgment

I confirm that:

• All my questions have been answered satisfactorily
• I have received written materials about the procedure/treatment
• I understand that no guarantees have been made regarding outcomes
• I have informed my physician of all my known allergies and medications

Signatures

Patient/Legal Guardian: _________________ Date: _________

Physician: __________________________ Date: _________

Witness: ____________________________ Date: _________

Emergency Contact

Name: _________________________ Relationship: ___________________ Phone: ________________________

This consent is valid for 30 days from the date of signature