Biopsy / Aspiration Procedure Consent Form

Patient details

First Name *

Last Name *

Mobile number *

Date of Birth *

Date of your booking *

Which centre are you attending? *

Consent

Your doctor has requested that we perform one of the following interventional procedures for you:

Fine Needle Biopsy / Core biopsy of region of interest
Aspiration / Aspiration biopsy

An Image guided Biopsy or aspiration is performed to obtain a sample from a specific area to enable us to determine the nature of the lesion or area.

Your radiologist will perform either a fine needle aspiration to sample cells from the area and / or a core biopsy which samples more tissue for the pathologist to review.

Local anaesthetic will be used to numb the region first, followed by up to 3-4 passes through the area to ensure enough cells are collected.

The samples we collect will be sent to a Pathology Lab for assessment and the results will be sent directly to your referring physician. The results can take up to 4 working days.

You may experience some pain in 1-2 hours after the procedure when the anaesthetic has worn off. You may also develop a bruise at the biopsy site and have a “bruise” type pain for a day or two.

As with any procedure involving needles, there is a small risk of infection. This risk is reduced by using a sterile aseptic technique, which involves thoroughly cleaning the skin with antiseptic and the use of new sterile needles. It is very important you consult your GP as soon as possible, or contact us, if you experience any of the following post procedure:

• You experience pain for more than 48 hours after the injection;

• Pain develops more than 2 days after the injection;

• The area becomes red, hot or swollen; or

• You develop a fever following the injection

The above symptoms may be signs of an infection and need to be treated as soon as possible.

Please answer the following questions:

Do you have any allergies? *

No Yes (please list)

Do you take any blood thinning medications? (eg aspirin) *

NoYes (please list)

Allergy *

Blood thinning medication *

I have read and understood the information above, and understand the risks involved. I do hereby consent to the above stated procedure.

I consent to Synergy Radiology accessing my external medical records, where possible, to provide relevant clinical information to assist in performing my procedure.

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Performing Radiologist:

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Consultation

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Specimen sent:

YesNo

Procedure performed:

Medication injected and #amps:

PRE pain score

POST pain score