Christian Hospital Office: 314-741-9010 DePaul Office: 314-739-8844 OFallon Office: 636-561-5020 St. Lukes Office: 314-434-3433 St.

Peters Office: 636-939-9202 Exchange: 314-388-6575

CONSENT TO PERFORM A PROSTATE ULTRASOUND & BIOPSY This prostate ultrasound and biopsy is being performed because it has been determined that I am at risk of having prostate cancer, either because of an elevated PSA blood level, a rising PSA level or an abnormal prostate examination. Even if cancer is present, it is possible this biopsy may not detect it. Therefore it is important for me to return for additional office visits, examinations, and blood tests in the future. Additional biopsies may be needed if there is a high suspicion of prostate cancer. This prostate biopsy involves placing an ultrasound probe into my rectum. Numerous biopsies will be taken with a small needle and sent to a pathology laboratory where a physician will determine whether biopsies are benign or malignant. As with all procedures, side effects or complications may occur. They include but are not limited to the following: blood in the urine, blood in the rectum, infection, difficulty voiding, injury to the urinary tract, injury to the rectum or some other problem which requires further treatment or hospitalization. In addition, the doctor has explained to me that there are alternative methods available such as delaying the biopsy and returning for further examinations and PSA levels. However, delaying a biopsy may allow a cancer to grow undetected and result in a situation where the cancer is less likely to be curable. I understand the above risks and alternatives and hereby give permission to proceed with the prostate ultrasound and biopsy.

Patient Signature

Date

__________________________________________ Print Name

________________________ Date of Birth

9/2012