Medical Voiding Cystourethrogram (VCUG) Consent Form

Streamline VCUG Consent with a Professional Digital Form

A voiding cystourethrogram (VCUG) is a specialized imaging procedure used to evaluate bladder function and detect vesicoureteral reflux, commonly performed on pediatric and adult patients experiencing urinary tract issues. Obtaining proper informed consent is essential—not just for regulatory compliance, but to ensure patients and families understand the catheterization process, radiation exposure, and what the procedure involves.

This Medical Voiding Cystourethrogram Consent Form template is designed for urology departments, radiology clinics, pediatric hospitals, and outpatient imaging centers that need a clear, compliant way to collect patient information, explain the procedure, and document authorization before a VCUG exam.

Built for healthcare providers who value clarity and compliance

Traditional paper consent forms create administrative friction—they're easy to lose, hard to read, and require manual filing and retrieval. This Paperform template replaces that workflow with a professional digital experience that patients can complete on any device, with responses securely stored and instantly accessible to your care team.

The form walks patients or guardians through patient demographics, medical history relevant to bladder and kidney function, allergy screening (especially iodine and contrast sensitivities), and a detailed explanation of the VCUG procedure including catheterization, contrast administration, fluoroscopic imaging, and voiding phase monitoring. Conditional logic ensures that only relevant follow-up questions appear based on patient age, medical history, and specific risk factors.

What makes this template effective for VCUG procedures

• Procedure-specific education: Includes clear language explaining catheterization, contrast dye use, radiation exposure, and what to expect during and after the exam
• Risk acknowledgment: Covers potential complications such as infection, allergic reactions, discomfort, and rare adverse events
• Pediatric-friendly options: Conditional fields for parental/guardian consent when treating minors
• Medical history capture: Gathers critical information about prior UTIs, kidney conditions, previous imaging, and current medications
• Allergy screening: Flags contrast, iodine, latex, and medication sensitivities before the procedure
• Digital signatures: Patients and guardians can sign electronically, with timestamps for legal documentation
• Instant retrieval: No more hunting through filing cabinets—submissions are searchable and accessible from your dashboard

Extend your workflow with Stepper and Papersign

Once a patient submits their consent form, you can use Stepper to automate the next steps: notify the radiology team, add the appointment to your scheduling system, send pre-procedure instructions via email or SMS, and update the patient's chart in your EMR. If you need a more formal contract or multi-party signature process, Papersign can turn the submission into a legally binding document with full audit trails and secure storage.

Designed for urology, radiology, and pediatric care teams

Whether you're a pediatric urologist, radiology department manager, or outpatient imaging coordinator, this template helps you replace outdated paper workflows with a modern, mobile-friendly consent process. It's ideal for hospitals, specialty clinics, diagnostic imaging centers, and any healthcare provider performing VCUG exams who wants to improve patient experience while maintaining rigorous documentation standards.

Paperform is SOC 2 Type II compliant and built for healthcare teams that need secure, scalable solutions—but please note that Paperform is not HIPAA compliant. For HIPAA-covered workflows, consult your compliance team about appropriate safeguards or consider this template as part of a pre-registration process with additional privacy controls.