TRANSVAGINAL ULTRASOUND CONSENT - Adelaide MRI

TRANSVAGINAL ULTRASOUND CONSENT

A transvaginal ultrasound is an optional procedure performed with an ultrasound transducer inserted into the vaginal canal. Generally, higher resolution images are obtained the closer the ultrasound transducer is to a structure of interest. This examination often provides more detailed images which may aid in the diagnosis.

You are under no obligation to have this examination performed and it will only be performed with your consent. If at any stage during the examination, you feel uncomfortable or do not wish to continue, please let the sonographer know and the examination will be terminated immediately.

If you have any questions or concerns; please address the sonographer prior to or during the examination.

The procedure has been explained to me; I understand the following:

- Strict sterile technique will be enforced. - The ultrasound transducer will be inserted into my vagina. - The sonographer will move the transducer during the procedure to obtain the required images. - I may request a third party to be present during the examination to act as a chaperone. - I may request for the examination be stopped at any time during the procedure. - This examination may not always provide better image quality.

I consent for the examination to be performed: I am allergic to latex:

YES

NO (please circle)

YES

NO (please circle)

Sonographer: ______________________________ Chaperone: __________________________________________

NAME: ___________________________________ SIGNATURE:__________________________ DATE:___/___/___.

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