consent 
Print Friendly Version EXPLANATION OF PROCEDURE
Direct visualization of the digestive tract with lighted instruments is referred to as gastrointestinal endoscopy. At the time of your examination, the lining of the digestive tract will be inspected thoroughly and possibly photographed. If an abnormality is seen or suspected a small portion of tissue (biopsy) may be removed or the lining may be brushed. These samples are sent for laboratory study to determine if abnormal cells are present. Small growth (polyps), if seen, may be removed. The procedure may be performed utilizing conscious sedation.
BRIEF DESCRIPTION OF ENDOSCOPIC PROCEDURES• EGD (Esophago-Gastro-Duodenoscopy): Examination of the esophagus, stomach, and duodenum. If active bleeding is found, coagulation may be performed to stop the bleeding.
• DILATATION: Dilating tubes or balloons are used to stretch narrow areas of the esophagus or colon.
• COLONOSCOPY: Examination of all or part of the colon. Polypectomy (removal of small growths called polyps) is performed, if necessary, by placing a wire loop or special biopsy instrument together with electric current.
• FLEXIBLE SIGMOIDOSCOPY: Examination of the anus, rectum, and sigmoid colon.
PRINCIPAL RISKS AND COMPLICATIONS OF GASTROINTESTINAL ENDOSCOPYGastrointestinal endoscopy is generally a low risk procedure. However, all of the complications listed below are possible. Your physician will discuss their frequency with you, if you desire, with particular reference to your own indications for gastrointestinal endoscopy. YOU MUST ASK YOUR PHYSICIAN IF YOU HAVE ANY UNANSWERED QUESTIONS ABOUT YOUR TEST.
PERFORATION: Passage of the instrument can cause an injury to the gastrointestinal tract wall with possible leakage of gastrointestinal contents into the body cavity. If this occurs, surgery to close the leak and/or drain the region is required.
BLEEDING: If bleeding occurs, it is usually a complication of biopsy, polypectomy, or dilatation. Management of this complication may consist only of careful observation, may require transfusions, or possibly a surgical operation.
SEDATION /MEDICAL REACTION: I understand that sedation involves additional risks and hazards but request the use of sedation for the relief and protection from pain during the procedure(s). I understand that certain complications may result from the use of sedation including respiratory problems or drug reactions. This procedure may be uncomfortable; we will make every attempt to sedate you. We however cannot guarantee that you will be pain free. Medications given by vein may also irritate the vein in which they are injected. I acknowledge that I am not to drive a motor vehicle before tomorrow.
OTHER RISKS: Include drug reactions and complications from other diseases that you may already have. Instrument failure and death are extremely rare, but remain remote possibilities. YOU MUST INFORM YOUR PHYSICIAN OF ALL YOUR ALLERGIC TENDENCIES AND MEDICAL PROBLEMS.
ALTERNATIVES TO GASTROINTESTINAL ENDOSCOPYAlthough gastrointestinal endoscopy is an extremely safe and effective means of examining the gastrointestinal tract, it is not 100% accurate in diagnosis. In a small percentage of cases, a failure of diagnosis or misdiagnosis may result. Other diagnostic or therapeutic procedures, such as medical treatment, x-ray, and surgery are available. Another option is to choose no diagnostic studies and/or treatment. Your physician will be happy to discuss these options with you.
ADVANCED MEDICAL DIRECTIVES: Please note that Advanced Medical Directives will not be honored within the Center and that in the event of a life threatening event, emergency medical procedures will be implemented; the patient stabilized and transferred to an acute health care facility where the decision to continue or terminate emergency measures can be made by the attending physician and family.
OTHER CONSENTS : In the event the physician or staff is exposed to my blood, body fluids or contaminated materials, I agree to allow testing that will determine the presence of HIV and Hepatitis. An accredited laboratory, at no cost to me, will perform all required laboratory tests.
OWNERSHIP: I am aware that Drs. Goldklang, and Kumar have an ownership interest in The Endoscopy Center. If I choose to go to another health care facility for this procedure, it will have no effect upon my relationship with my doctor.
I certify that I understand the information regarding gastrointestinal Endoscopy procedure(s). I have been fully informed of the risks and possible complications of my procedure(s). I hereby authorize and permit
Dr. _____________________________ and whomever he may designate as his assistant to perform upon me the following:
[] ESOPHAGO-GASTRODUODENOSCOPY with possible dilation [] COLONOSCOPY [] FLEXIBLE SIGMOIDOSCOPY [] OTHER ______________________________________
If any unforeseen condition arises during this procedure calling for additional procedures in the physician's judgement, treatments or operations, I authorize him to do whatever he deems advisable. I am aware that the practice of medicine is not an exact science, and I acknowledge that no guarantees have been made to me concerning the result of this procedure.
PATIENT SIGNATURE__________________________WITNESS_________________________DATE/TIME_____________
Signature of Responsible adult (If patient cannot sign)_____________________________________
.
