Hsg consent form 2025

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The document is a consent form for a hysterosalpingogram (HSG) procedure at Premier Fertility Center. It outlines the purpose of the HSG, which is to evaluate the uterine cavity and fallopian tubes using x-ray imaging and contrast dye. The document details the procedure, potential risks, and post-procedure instructions, emphasizing the importance of understanding the benefits and risks involved. It requires patient acknowledgment and signatures from both the patient and physician.

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What are the restrictions for HSG test?

It is also not advised to perform this procedure during the menstrual period or immediately after it, due to the increased risk of intravasation of contrast with open uterine vessels. Hypersensitivity to contrast agents is obviously a contraindication to its use in this procedure.

Can I make my own consent form?

Considerations in preparing the informed consent document: Elements of consent present. Complete explanations. Lay language. Protection of confidentiality. No unproven claims of effectiveness. Device studies include a statement that the study includes an evaluation of the safety of the test article.

What should you not do before an HSG?

The procedure will be scheduled only on days 6-12 after the first day of your last menstrual period. A day or two before the exam, avoid sexual intercourse, stop using creams or other vaginal medications, and avoid douching. You may take over-the-counter pain medications a few hours before the test.

What are the requirements for an HSG test?

Preparation for a Hysterosalpingogram Procedure The exam should take place between 7-10 days after the beginning of your last menstrual period. A course of antibiotics may be prescribed prior to the test depending on your referring providers recommendations. You can eat and drink as per usual the day of the test.