Home / Training / Manuals / A practical manual on visual screening for cervical neoplasia / Appendix / Informed consent
The doctor/health worker explained to me in detail about the vinegar (VIA)/iodine (VILI) test(s)* for the early detection and prevention of cancer in the neck of my womb (uterine cervix). I understand that the surface of my cervix will be visually inspected after application of 5% acetic acid/dilute iodine solution to detect or to exclude precancer/-cancer. I understand that these procedures are generally harmless, but may occasionally cause some irritation or mild bleeding, which can be easily controlled.
I understand that, if the test is positive, other tests such as magnified inspection of the cervix with an instrument called a colposcope and examination of a sample of the tissue in my cervix (biopsy) may be recommended before treatment is provided. I have been informed that treatment by medicines or cryotherapy (destroying the diseased portion of the cervix by an ice-cold metal probe) or removing the diseased portion by minor surgery or major surgery and/or treatment with with x-rays, may be required, in the event of any abnormality (infection or precancer or cancer or complications) being detected.
I hereby express my willingness to undergo the above tests and treatment, if advised.* / I am not willing to undergo the above procedures. *
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* Delete as appropriate
A practical manual on visual screening for cervical neoplasia
Appendix 2 / Informed consent
I understand that, if the test is positive, other tests such as magnified inspection of the cervix with an instrument called a colposcope and examination of a sample of the tissue in my cervix (biopsy) may be recommended before treatment is provided. I have been informed that treatment by medicines or cryotherapy (destroying the diseased portion of the cervix by an ice-cold metal probe) or removing the diseased portion by minor surgery or major surgery and/or treatment with with x-rays, may be required, in the event of any abnormality (infection or precancer or cancer or complications) being detected.
I hereby express my willingness to undergo the above tests and treatment, if advised.* / I am not willing to undergo the above procedures. *
Signature:
Date:
Name:
Address:
* Delete as appropriate