INTERVENTIONAL RADIOLOGY

PATIENT INFORMATION AND CONSENT FORM

Near East University Hospital has requested for me to have this treatment.

I was informed about the........................................ procedure by my doctor and nurse /

radiographer.

I was reassured that this examination is purely done for diagnosis / treatment reasons only.

My doctor has explained to me that the procedure will take.......... minutes.

During the procedure allergic reactions, anaphylactic shock, hemorrhage, pneumothorax,

infection, death or other complications (adverse events) may occur. I understand that I may need
to stay longer at the hospital for further treatment if some of these unlikely events occur.

Despite adequate medical treatment, I understand that in rare cases my sickness can reoccur
and therefore further treatment may be required. I also understand that ultrasound, computed
tomography and blood tests might be required after my operation.

Certain intervals after the procedure with my disease by, and I know some may be treated with
blood tests.

I'm not about to accept this process, experiencing a challenging behavior. If you decline the
transaction, with the physician and the associate medical bakımıma not bring any harm to know
that.

Made me realize I have all the explanations in detail. At the end of a time to think on my own
diagnosis / treatment I received the decision. Scheduled for diagnostic / treatment process, I
agree.

Doc Name - Signature

The patient and or the Patients' Relatives

Name - Signature