Documents the patient's informed consent to extracorporeal shock wave lithotripsy (ESWL) for kidney or ureteral stones, including stone fragmentation technique, sedation, risks, and alternatives.
The Lithotripsy (ESWL) 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, urology, lithotripsy, eswl, kidney stones. 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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# Lithotripsy (ESWL) Informed Consent > **Important — not medical advice.** For use by a licensed provider; tailor to the patient, your protocols, and state law. This document records your voluntary informed consent to extracorporeal shock wave lithotripsy (ESWL). Your urologist or a qualified designee has discussed, or will discuss, the following information with you. Please read carefully and ask any questions before signing. --- ## Patient Information **Patient Name:** ___________ **Date of Birth:** ___________ **Medical Record Number (if known):** ___________ **Treating Urologist:** ___________ **Facility:** ___________ **Planned Procedure Date:** ___________ --- ## 1. Indication ESWL has been recommended for the following stone(s): **Stone location:** ___________ **Approximate stone size (mm):** ___________ **Stone composition (if known):** ___________ **Pre-procedure stent placed?** ___________ --- ## 2. Description of the Procedure