Temporal Artery Biopsy Consent Form
Please complete this form to review and confirm consent for a temporal artery biopsy procedure.
Patient Information
Patient Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Procedure Information
Referring Clinician Name
*
First Name
Middle Name
Last Name
Procedure Date and Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Biopsy Side / Location
*
Please Select
Left
Right
Bilateral
As directed by clinician
Consent and Attestation
Acknowledgment and Consent
*
I understand the temporal artery biopsy procedure, its purpose, and the common risks and benefits have been explained to me, and I agree to proceed.
Patient Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: