Sample Consent:

There are possible side effects to any medical procedure we do. Side effects will including side effects of anasthesia or the procedure itself.

We had a discussion today about the condition and discussed possible management options. We did discuss possible non surgical as well as surgical options, and she chose surgery.
We discussed possible routines, including Abdominal Hysterectomy, vaginal hysterectomy and possible laparoscopic assisted hysterectomy.
We also discussed the option of keeping the ovaries as well as taking them out, and her choice was
Keeping ovaries
Taking ovaries out.

We discussed possible taking of the tubes out, and she has chosen to have her tubes taken out.

We discussed possible side effects and complications, including\

Complications of anaesthesia, depending on type used

These may include: 

Possible infection at the site of the IV access. Possible chipping of teeth, crowns, dislodging teeth. Possible pain in the throat after the procedure, from the breathing tubes.  Rarely aspiration and pneumonia, lung collapse, rarely a heriditary condition call Malignant Hyperthermia.

The anesthetist will have a more detailed conversation with you about this complications.

Complications of surgery itself: Hysterectomy
Bleeding and possible blood transfusion
Infections and  need antibiotic prophylaxis
Injury of internal organs, ureter, bladder, intestines, colon, blood vessels,
Possible clots in the legs or lungs DVT/PE and heparin prophylaxis, and possible hematomas formation and bleeding
Not being able to get pregnant again
Rarely not being able to continue the procedure as planned, example: ending up with open surgery when we started with laparoscopic hysterectomy, whether the cause is equipment malfunction, technical difficulty or occurance of complication.
Scar on abdomen, pain after surgery, etc.
We did discuss changes (and lack thereof) of body function, effect on sexuality, body image, as well as recovery, 2-6 weeks of work and no sexual activity.

There are no garantees that if the procedure is started laparoscopically that it will end laparoscopically. 

We did discuss, (where appropriate) the financial obligations associated with this procedure. It was made clear to the patient (and parties involved) the portions needed to be paid out if pocket and what is covered by insurance. 

We did discuss that in the case of emergency, and after discharge, that she will either

-contact us

-visit the nearest emergency department of local hospital, clinic or other emergency health care provider.

-other arrangement as in here.......

We discussed management in case of severe bleeding, severe pain, or high temperature, abnormal discoloration in urine or around the wound, inability to urinate, or have bowel movement, abdominal distention, inability to breath well, pain in the chest, swelling or pain in the legs, 

She was given time to ask questions and decide, and did sign the consent for surgery.