Documents the patient's voluntary informed consent to uterine fibroid embolization (UFE), including procedure description, indication, risks, benefits, and alternatives such as myomectomy and hysterectomy.
The Uterine Fibroid Embolization 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, gynecology, ufe, interventional radiology, fibroid. 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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# Uterine Fibroid Embolization 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 uterine fibroid embolization (UFE). Your interventional radiologist or a qualified designee has discussed, or will discuss, the following information with you before the procedure. Please read carefully and ask any questions before signing. --- ## Patient Information **Patient Name:** ___________ **Date of Birth:** ___________ **Medical Record Number (if known):** ___________ **Referring Physician:** ___________ **Performing Interventional Radiologist:** ___________ **Facility:** ___________ **Planned Procedure Date:** ___________ --- ## 1. Indication I have been diagnosed with symptomatic uterine fibroids (uterine leiomyomata). My symptoms and/or imaging findings that indicate UFE include: ___________ --- ## 2. Description of the Procedure Uterine fibroid embolization is a minimally invasive, image-guided procedure performed by an interventional radiologist. Under fluoroscopic (X-ray) guidance: 1. A small incision is made in the skin, typically at the wrist (radial) or groin (femoral artery). 2. A catheter (thin, flexible tube) is advanced through the artery and positioned selectively in each uterine artery.