Informed Patient Consent Form For Core Biopsy
Procedure
Core Biopsy of which breast(s).
Thank you for entrusting us with your health care. This is an “Informed Consent Form.” Its purpose is to inform you about your core breast biopsy, which your physician(s) has recommended you undergo. You should read this form carefully and ask any questions before you decide whether to give your consent for this procedure.
PURPOSE OF THIS PROCEDURE: The purpose of the core breast biopsy is to obtain a small quantity of tissue in the precise location of your breast where there is abnormality. The procedure starts with cleansing the skin with betadine. The radiologist will inject local anesthetic into the skin and breast to numb the area needing the biopsy. After numbing the skin with a local anesthetic, a biopsy needle is then placed into the abnormality through a small skin nick, obtaining a sample of tissue, which can then be microscopically analyzed. Multiple breast biopsy samples are removed, to obtain a satisfactory quantity of tissue for analysis. After removal of the biopsy specimens, one or more small metal markers are usually placed in the breast to mark the biopsy site in case post - biopsy surgery is needed. The markers also help us read the follow-up imaging studies. There are no known harmful effects from the metal markers. After the completion of the procedure, a small bandage will be placed on the breast to prevent infrequently occurring bleeding.
RISKS: The main risk of core breast biopsy is localized bleeding in the breast because of placement of the needle. Though this procedure is performed with “sterile technique,” infection of the breast may occur in extremely rare circumstances, requiring treatment with antibiotics.
AFTERCARE: No exercise or heavy lifting for the next two (2) days after the procedure. A sports bra must be worn also for a few days after the procedure to help reduce the swelling of breast.
Waiver & Consent
Your confirmation on this form indicates:
- That you have read and understood the information provided in this form.
- That you have been verbally informed about this procedure by the Radiologist
- That you have had a chance to ask questions
- That you have received all the information you desire concerning the procedure, and that you authorize and consent to the performance of the 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.
Radiologist Name