Informed Consent for Diagnostic Medical Sonography

Patient Name: ____________________________________ D.O.B.:______________________

Proposed Mode of Treatment:

I, ______________________, hereby give Harper Medical Imaging permission to perform an ultrasound which has been requested by my physician. I understand that I may receive either a standard, extensive or vaginal sonogram which are done with sound waves from the ultrasound probe that bounce off the uterus and the developing baby producing echo which the computer then converts to images.

Reason for treatment:

I understand the following:
A standard sonogram will provide information concerning the location, fetal position, twin pregnancies, gestational age and/or the possibility of malformation.

A extensive sonogram will provide the same information as the standard scan plus a more detailed evaluation of the fetal’s growth and/or abnormalities.

A vaginal sonogram is an instrument about the width of a tampon which is inserted into the vaginal canal. This type of sonogram provides very detailed views of the uterus, ovaries, or portions of the fetus that are low in the pelvis. It may also be done to see the heartbeat, the location of a very early pregnancy or to evaluate the placenta or birth canal. Such as the other ultrasounds, the vaginal ultrasound procedures are just as safe. It is normally less uncomfortable than pap smears.

Risks involved:
Diagnostic ultrasound has been used for pregnancies for many years. Ultrasounds are a safe procedure that uses the lowest amount of energy providing an accurate assessment. There are no known risks. Ultrasounds should only be requested by a physician of licensed health care provider for medical reasons. Your ultrasonographer has been trained in appropriate use of ultrasound energy.

Alternatives and risks of alternatives:
There are other reliable ways to determine the gender and certain abnormalities. With these alternatives, there are risks involved.

Amniocentesis is a procedure in which a needle is inserted into the uterus, and it removes a small amount of amniotic fluid surrounding the baby and then analyzed.

Amnio risks include:

Infection: Rarely this procedure may trigger a uterine infection.
Infection transmission: Infections such as hepatitis C, toxoplasmosis or HIV can be transferred.
Leaking amniotic fluid: rarely, amniotic fluid may leak through the vagina however, the pregnancy is lifeless to proceed normally. If chronic leakage, there may be orthopedic problems with baby.
Miscarriage: between 1 in 300 and 1 in 500 women during the second trimester and higher if done before the 15 weeks of pregnancy.
Needle Injury: the baby may move in the path of the needle. Serious needle injuries are rare.
Rh sensation: Rarely, this procedure may cause the baby’s blood cells to enter the mother’s bloodstream. If you are Rh negative, you will be given a drug to prevent you from producing antibodies against your babies blood cells.

Another test that can be done as an alternative is Chorionic villus sampling. This is a serious and invasive procedure that reveals whether the baby has a chromosomal and genetics condition. During this procedure, a sample of the cells are taken for biopsy and then checked for problems earlier in pregnancies, usually at 10 -12 weeks.

CVS risks include:
Infection: Rarely this procedure may trigger a uterine infection.
Miscarriage: 1 in 400 women. The risk runs higher if the sample if taken through the cervix rather than the abdominal wall and if the baby is smaller than normal.
Rh sensation: This procedure may cause the baby’s blood cells to enter the mother’s bloodstream. If you are Rh negative, you will be given a drug to prevent you from producing antibodies against your babies blood cells.

Risks involved if treatment is refused:

If ultrasound is refused, you may run the risk of not knowing of medical conditions and/or abnormalities.

I have read and understood the above information completely. I hereby authorize Harper Medical Imaging to perform the designated procedure(s). If I have any questions, I will make sure to discuss them with my physician before undergoing the procedure.

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Patient’s Signature Date/Time Physician/Provider’s Signature Date/Time

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Witness Date/Time Interpreter Date/Time