Pessary fitting consent form

Patient Name*

First NameLast Name

Date of Birth*

DayMonthYear

Clinician

First NameLast Name

* Please enter either a landline or mobile number below. This is required if we need to contact you about the information you provide on this form. Your private data will not be shared with any third party.

Your Mobile Number

Mobile phone number

Your Landline Number (unnecessary if mobile number provided)

Area CodePhone Number

Email

example@example.com

Type of prolapse and diagnosis:

Have you had, or are you awaiting surgery for your prolapse?

(Please provide approx. dates)

Obstetric history

(Number of children and type of delivery with dates)

Are you currently breast feeding?

YesNo

Are you…

Pre-menopausalPeri-menopausalPost-menopausal

Are you using vaginal oestrogen?

YesNo

Please list any past medical history:

(e.g. diabetes, high blood pressure, any surgery)

Please list any medications that you are currently taking:

(Including any HRT)

Could you currently be pregnant?

YesNo

*If you are pregnant this may influence the decision to fit a pessary

Occupation

Name of your G.P.*

First NameLast Name

Address of G.P Surgery

Street Address

Street Address Line 2

CityCounty

Postal Code

We recommend that you inform your G.P. that you will be attending this consultation which may include the insertion of a pessary. You will be sent a letter after the consultation outlining assessment findings and treatment, this should also be passed on to your G.P.

Download the Pessary Patient information Sheet here:

Signature (To draw your signature: Place the mouse cursor in the area below, click and hold the left mouse button then move the mouse as if you were drawing) *

I confirm that the practitioner has explained the information above and given me the opportunity to ask any questions. I have also discussed what the procedure is likely to involve, the benefits and risks of any available alternative treatments (including no treatment) and any particular concerns. I agree to the procedure or course of treatment described on this form.*

Accept

Once we receive the completed form, this will then be screened by one of our senior clinicians. Once approved, one of our booking team will contact you to get you booked for an appointment – please note we aim to screen all consent forms within a maximum of 1-2 working days.

DateTime

Pessary Fitting