A Pelvic Examination is an examination of the vagina, cervix, uterus, fallopian tubes, ovaries, rectum or external pelvic tissue or organs (including scrotum, testicles, penis, prostate). This procedure is used to diagnose and/or treat conditions that involve the pelvis. It may be perform using any combination of modalities, which may include the health care providers gloved hands and instrumentation. For purposes of this consent, vaginal sonography performed by ultrasound technician is included.

to perform a pelvic examination, including vaginal sonography, as described above. By my signature below, and I acknowledged that I have read and understand the content of this form.