Aryian L. Cooke, M. D

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Aryian L. Cooke, M.D.

11355 Pembrooke Sq.

Suite 108A

Waldorf, MD 20603

P 240.252.2140

F 240.252.2141

Hysteroscopy and NovaSure® Consent Form

I hereby consent Dr. Aryian L. Cooke to perform the NovaSure® endometrial ablation with hysteroscopy.

I understand this is a procedure to permanently remove the uterine lining to significantly reduce or eliminate excessive vaginal bleeding and associated symptoms. I also understand that becoming pregnant after an endometrial ablation procedure may be dangerous for both mother and fetus, and I should continue to use contraception.
It has been explained to me that a lighted viewing device (hysteroscope) will be inserted through the vagina for a visual examination of the interior of the uterus. The NovaSure® endometrial ablation device will then be inserted to perform the endometrial ablation, which will take two minutes or less to complete.
As with any surgical procedure, complications may occur. Some possible complications of the hysteroscopy and endometrial ablation include, but are not limited to: bleeding, infection, perforation of the uterine wall or bowel, or procedure failure. In the rare instance of a uterine perforation, a laparoscopy may be required for further evaluation.
After the procedure, I will report any of the following: foul-smelling discharge or drainage from the vagina, fever and/or chills, severe abdominal pain, excessive bleeding, or heavy bleeding for more than two days after the procedure.
I authorize the administration of anesthesia as deemed necessary.

___________________________________ ___________________________________


I certify that I personally explained the need for surgery, the nature of the procedure, its risks and alternatives to the patient.



If you have any questions prior to your procedure please call our office at 240.252.2140


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