Form#5 Pelvic Exam Form

Pelvic Examination(s) Consent Form for Adult or Pediatric Female Patient
A new law went into effect requiring written consent for a pelvic examination on patients. Your provider has determined that the examination described below is medically necessary and appropriate.

The law defines pelvic examination as the series of tasks that comprise an examination of the vagina, cervix, uterus, fallopian tubes, ovaries, rectum, or external pelvic tissue or organs using any combination of modalities, which may include, but need not be limited to, the health care provider’s gloved hand or instrumentation.

The pelvic examination(s), as indicated, has been explained to me and my questions have been answered.

I hereby consent to my health care practitioner and / or associates and or assistants as may be selected by said health care practitioner to perform the pelvic examination(s).
By initialing here, I also consent to receive a pelvic examination from a medical student or any student receiving training as a health care practitioner under the supervision of a health care practitioner.

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Patient Name*

First NameLast Name
Patient Signature*

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Date*

MonthDayYear
Date
Parent or Legally Authorized Person Signature Relationships

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Guarantor Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

Pelvic Examination(s) Consent Form for Adult or Pediatric Female Patient