Thank you for entrusting us with your health care. This is an “Informed Consent Form.” Its purpose is to inform you about your lung biopsy, which your physician(s) has recommended you undergo. From the lung biopsy more information can now be provided to help your doctor with the correct treatment. You should read this form carefully and ask any questions before you decide whether to give your consent for this procedure.

What is a lung biopsy:

This is a procedure aimed at taking a small sample of an abnormal area of lung with a fine needle, without having an operation.

Risks and complications to the procedure that will be explained:

• Bleeding.
• Infection, which may require the use of antibiotics.
• Damage to nerves or blood vessels and surrounding structures.
• Pain after surgery, which may require you to take pain medication.
• Pneumothorax
• Chest tube
• Death

Waiver & Consent

By your confirmation below, you authorize and direct:

to perform the liver biopsy 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 described above has been adequately explained to you, you have had the opportunity to ask questions, and you have received all the information you desire concerning the Lung Biopsy.
3. You authorize and consent to the performance of the Lung Biopsy 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.