Informed consent for diagnostic or operative hysteroscopy for evaluation and treatment of intrauterine pathology including polyps, fibroids, septum, and adhesions.
The Hysteroscopy Informed Consent is a ready-to-use healthcare & wellness template you can send for signature in minutes. It is written for 1 signer (patient) and, by default, expires 30 days after it is sent if left unsigned. It covers consent, obgyn, hysteroscopy, uterine procedure, gynecologic surgery, reproductive health. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# Hysteroscopy Informed Consent > **Important — not medical advice.** For use by a licensed provider; tailor to the patient, your protocols, and state law. **Patient Name:** ___________ **Date of Birth:** ___________ **Medical Record Number:** ___________ **Ordering Provider:** ___________ **Planned Procedure Date:** ___________ --- ## 1. Procedure I, the undersigned patient, consent to hysteroscopy performed by my healthcare provider. **Procedure type:** ___________ **Setting:** ___________ **Planned anesthesia / analgesia:** ___________ Hysteroscopy uses a thin, lighted telescope (hysteroscope) inserted through the cervix into the uterine cavity to directly visualize the inside of the uterus. A fluid medium (normal saline or electrolyte-free fluid depending on energy source) distends the uterine cavity for visualization. **Diagnostic hysteroscopy** involves visual inspection of the uterine cavity, tubal ostia, and endometrium, with directed biopsy if indicated. **Operative hysteroscopy** uses specialized instruments (scissors, loop resectoscope, morcellator, or ablation device) passed through the hysteroscope to treat identified pathology. Common operative procedures include: - **Polypectomy:** Removal of endometrial or endocervical polyps - **Myomectomy:** Resection of submucosal or intracavitary fibroids using a resectoscope or intrauterine morcellator - **Adhesiolysis:** Lysis of intrauterine adhesions (scar tissue / Asherman's syndrome) - **Septal resection:** Incision and removal of a uterine septum to restore normal uterine cavity shape - **Endometrial ablation:** Destruction of the endometrial lining to treat abnormal bleeding (note: ablation is not contraception; pregnancy after ablation is dangerous) - **Retained products of conception removal:** Evacuation of retained placental or gestational tissue ---