Thank you for entrusting us with your health care. This is an “Informed Consent Form.” Its purpose is to inform you about your FNA, which your physician(s) has recommended you undergo. FNA results provide your doctor with the diagnostic information needed to plan appropriate follow up or treatment specific to your medical situation. You should read this form carefully and ask any questions before you decide whether to give your consent for this procedure.

Details of FNA procedure are as follows: FNA is a simple, safe, and accurate method of determining the nature of a lump or swelling that can be both palpable and non-palpable. The procedure will consist of placing a small “fine” needle into the lump to retrieve cells, which are then stained and evaluated under the microscope by the Pathologist. The procedure starts with cleansing the skin overlying the palpable lump. This will be cold. The skin will then be injected with local anesthetics which produce a stinging or burning sensation. When the skin is numb, the doctor will then insert a small needle into the lump followed by gentle poking back and forth a few times. This will only take 5 – 10 seconds before the needle is removed. You may feel slight pressure, as the cells are aspirated. The aspiration may be repeated until adequate material is obtained. Every time a needle is placed into the lump, a new sterile needle will be used. After the completion of the procedure, a bandage will be placed over the aspiration site to prevent infrequently occurring bleeding. Routine activity can be carried out immediately after the procedure. No specific precaution is necessary.

Risks, complications and expected benefits of the FNA procedure:

• The risks of FNA are, for the most part, clinical. A definite diagnosis may not be obtained in 5-10% of cases. It is rare that a false negative or positive result may occur.
• The complications of FNA are few. These include bleeding at the sight, tenderness and infection.

Waiver & Consent

By your confirmation below, you authorize and direct:

to perform the FNA procedure on you. Your confirmation below further constitutes that:

1. You have read, you understand, and you agree to the conditions of this document.
2. The procedure set forth above has been adequately explained to you.
3. You have had the opportunity to ask questions, and you have received all the information you desire concerning the FNA procedure.
4. You authorize and consent to the performance of the FNA procedure and any anesthesia required in connection with such procedure.

Witness Confirmation

By clicking the "Confirm" button, you acknowledge that Apex Radiology has electronically witnessed this consent form. The date and time of submission are recorded and securely stored as part of your medical record.