UNC HOSPITALS CHAPEL HILL, NORTH CAROLINA REQUEST AND AUTHORIZATION FOR COLONOSCOPY, BIOPSY, AND POLYPECTOMY MIM#182
|
|
- Malcolm Richard
- 5 years ago
- Views:
Transcription
1 UNC HOSPITALS CHAPEL HILL, NORTH CAROLINA REQUEST AND AUTHORIZATION FOR COLONOSCOPY, BIOPSY, AND POLYPECTOMY MIM#182 I request and authorize and/or associates or assistants of his/her choice at the University of North Carolina Hospitals to perform a colonoscopy and biopsies on. Authorization also is Patient s Name given for the control of bleeding, removal of abnormal growths, and dilation of abnormal areas of narrowing of the gastrointestinal tract. If the procedure is performed under the supervision of an attending physician, I understand that residents and/or assistants of his/her choice at the University of North Carolina Hospitals may perform selected tasks, which may include: opening and closing a surgical site; dissecting tissue; removing tissue, blood or body fluids; injecting medication(s); administering anesthesia; implanting devices; inserting/removing/operating an endoscope for diagnosis or treatment; and placing invasive lines. At the time of the procedure, the attending physician will determine the extent of participation by the resident(s) and/or assistant(s) depending on: (1) the complexity of the procedure; (2) the unique circumstances of the patient; and (3) the training and experience of the resident(s) and/or assistant(s). Description of the Procedure: The colonoscopy will involve the insertion of a long, flexible, video/fiberoptic instrument called a colonoscope into my rectum. The colonoscope will allow providers to view and examine the lining of my entire large intestine. If any abnormalities are seen, a biopsy may be performed. A biopsy involves the removal of one or more small samples of tissue through the colonoscope, which will be examined by a pathologist. If a growth or polyp is discovered, it will be removed to the extent deemed safe and possible, using a wire loop and electrocautery, or a forcep and electrocautery. An electrocautery is an instrument that directs a high frequency electrical current through an area of tissue. Treatment procedures may be performed if colonoscopy identifies a source of recent active bleeding or a narrowing of my digestive tract. These procedures may include treating the site of bleeding with an electrocautery, laser, heater probe and/or injection of agents that cause blood to clot. Narrowed areas of the gastrointestinal tract may be enlarged by the use of balloons or tapered tubes of varied sizes. I understand that sedatives, such as Versed, Demerol, Droperidol and/or Morphine, will be given by intravenous line to cause relaxation and drowsiness. These 2/97 1 of 4
2 medications also may cause a brief period of memory loss and result in my not having a recollection of the procedure. Many patients sleep through the procedure, which typically takes 30 to 90 minutes. Risks: The following risks have been associated with a colonoscopy. 1. Slowing of breathing and abnormal heart rhythms. Intravenous medications may cause a slowing of breathing and, in rare cases, may cause breathing to stop. They also may cause lowering of blood pressure and/or abnormal heart rhythms. I will be carefully monitored for changes in my breathing, blood pressure and heart rhythms during and after the colonoscopy. 2. Perforation of the colon. A perforation or tear in the colon wall occurs in up to 4 per 1,000 colonoscopies. If a polyp is removed during the procedure, the risk of a perforation is 10 per 1,000 procedures. Perforations are treated with antibiotics and/or surgery, which could require a colostomy. 3. Bleeding. Bleeding may follow a biopsy or removal of a growth and may occur immediately or up to 2 weeks after the procedure. If a polyp is removed during the procedure, the risk of bleeding is 25 per 1,000 colonoscopies. Cases of excessive bleeding may require a blood transfusion, repeat colonoscopy, or surgery. 4. Injury to the spleen. Injury to the spleen has rarely been reported. 5. Infection. Patients with heart murmurs or artificial heart valves may be given antibiotics before a colonoscopy in order to reduce the risk of infection of the heart valves. 6. Other complications. Patients may rarely experience an unexpected, adverse drug reaction. Other possible complications of a colonoscopy include: inflammation, mild abdominal discomfort, injury to internal organs and bruising or infection at the intravenous site. 7. Death. Death as a complication of colonoscopy is extremely rare, but has been reported to follow a colonoscopy in 1 per 10,000 procedures, and 2 per 10,000 procedures in which a polyp was removed. 8. Missed abnormalities. Some growths and even some cancers are not seen during colonoscopy. This may occur if the colon is not completely clean, if there are blind areas in the colon, or if the 2/97 2 of 4
3 exam cannot be completed. Inability to complete the exam occurs in fewer than 5 per 100 colonoscopies. Benefits: I understand that the purpose of a colonoscopy is to gain information about the entire large intestine that may not be obtained by x-ray or by other diagnostic means, and to treat certain conditions. The procedure is generally very safe and is well tolerated by most patients. Alternative Options: I understand that x-rays and surgery are the alternatives to a colonoscopy. Statement of Voluntary Participation: I have read the information contained in this form, and have had sufficient opportunity to discuss my medical condition and treatment with the undersigned health care provider. All of my questions have been answered to my satisfaction, and I believe that I have been given adequate information upon which to base an informed consent for a colonoscopy, biopsy, and other possible therapeutic procedures. I am consenting to have a colonoscopy, biopsy, and other possible therapeutic procedures performed. I understand that I can withdraw my consent at any point. My consent for this procedure is voluntary. I understand that during the course of the colonoscopy something unexpected may arise which may necessitate procedures in addition to or different from those described above. If such unexpected circumstances arise I further request and authorize the performance of additional operations or procedures that may be considered necessary or advisable by the undersigned health care provider and/or his/her associates or assistants. I further request that the administration of such anesthetics as may be considered necessary, desirable, or advisable by the provider responsible for this service. Risks included with the administration of anesthesia or sedation analgesia include: severe blood loss, infection, damage to teeth, mouth, throat or vocal cords, nerve or eye damage, drug reaction, slowing or stopping of breathing, failure of the anesthetic or sedation analgesia, cardiac arrest, risks that cannot be predicted, permanent disability or even death. I understand these risks and I consent to the use of any anesthetic or sedation analgesia that my health care providers or the anesthetists believe is necessary. Do Not Resuscitate Orders: I understand that, if I/the patient have a Do Not Resuscitate (DNR) Order currently in effect, it will be suspended temporarily before, during and immediately after the therapy I/the patient will be undergoing unless I place my initials in the following space. Administration of Blood or Blood Products: I have discussed with my health care provider the possibility of administering blood or blood products before, during or after the operation or procedure during my current admission, or for the duration of planned 2/97 3 of 4
4 treatment up to one year, as long as my medical condition and proposed treatment and associated risks have not changed. I understand that I/the patient will be given medically necessary blood and blood products unless I place my initials in the following space. I am aware that the practice of medicine is not an exact science, and I acknowledge that no guarantees have been made concerning the performance, results, or interpretation of the colonoscopy. For the purpose of advancing medical education I give my permission for observers to be admitted to the operating room or procedure room, and for UNC Hospitals and the UNC School of Medicine staff to make and use any photographic or other illustrations of me for diagnostic, scientific, educational, or research purposes, provided that my identity is not revealed. I further authorize UNC Hospitals and the UNC School of Medicine staff to examine and dispose of any tissues or parts that may be removed and to use them for teaching, educational, or research purposes, provided that my identity is not revealed. I confirm that I have read this form, or it was read to me, and that all blank spaces were filled in and all inapplicable paragraphs, if any, were stricken before I signed below. Signature of Patient/Person Authorized to Sign for Patient Date & Time: Printed Name Hospital Number Relationship to Patient PROVIDER CERTIFICATION I hereby certify that the nature, purpose, benefits, usual and most frequent risks of, and alternatives to, the proposed colonoscopy, biopsy, and other possible therapeutic procedures have been explained to the patient (or person authorized to sign for the patient) either by a physician or by the provider who is to perform the procedure(s), that the patient has had an opportunity to ask questions, and that those questions have been answered. The patient or the patient s authorized representative has been advised that selected tasks may be performed by assistants to the primary health care provider(s). I believe that the patient (or person authorized to sign for the patient) understands what has been explained, and has consented to the operation or procedure. Provider Signature Provider Name Date: 2/97 4 of 4
5 WITNESS CERTIFICATION I hereby certify that the patient (or person authorized to sign for the patient) has EITHER (Check one box): 1. Acknowledged in my presence that he/she has requested a colonscopy, biopsy, and other possible therapeutic procedures and has received an explanation of the nature, purpose, benefits, usual and most frequent risks of, and alternatives to, the operation or procedure, understands that selected tasks may be performed by the health care provider s assistants/residents, has had all of his/her questions answered, has given his/her consent, and has signed the form above; OR 2. Answered "yes" to all of the following questions: a. Did a health care provider explain the operation or procedures to you? b. Did a health care provider explain that selected tasks may be performed by assistant(s)/resident(s)? c. Did a health care provider explain alternative procedures and treatments and their risks and benefits? d. Is this your signature on the consent form? e. Have you given your consent for the operation or procedures? f. Have all of your questions about the operation or procedures been answered? Witness Signature Witness Name Date & Time: 2/97 5 of 4
UNC HOSPITALS CHAPEL HILL, NORTH CAROLINA REQUEST AND AUTHORIZATION FOR UPPER GASTROINTESTINAL ENDOSCOPY AND BIOPSY MIM#180
UNC HOSPITALS CHAPEL HILL, NORTH CAROLINA 27514 REQUEST AND AUTHORIZATION FOR UPPER GASTROINTESTINAL ENDOSCOPY AND BIOPSY MIM#180 I request and authorize and/or associates or assistants of his/her choice
More informationEASTERN SHORE ENDOSCOPY, LLC (ESE)
EASTERN SHORE ENDOSCOPY, LLC (ESE) Endoscopy Consent An endoscopy is a medical procedure where your doctor, using a flexible video instrument (endoscope), looks at various areas inside of your body, which
More informationGARY M. ANNUNZIATA, D.O., F.A.C.P., / ANH T. DUONG, M.D. /JONATHAN C. LIN, M.D., MPH INFORMED CONSENT FOR COLONOSCOPY
GARY M. ANNUNZIATA, D.O., F.A.C.P., / ANH T. DUONG, M.D. /JONATHAN C. LIN, M.D., MPH INFORMED CONSENT FOR COLONOSCOPY YOU HAVE BEEN SCHEDULED FOR A COLONOSCOPY FOR THE PURPOSE OF EXAMINING YOUR COLON (LARGE
More informationLas Vegas Urogynecology
Las Vegas Urogynecology 7500 Smoke Ranch Road - #200 Las Vegas, NV 89128 Telephone: (702) 233-0727 Fax: (702) 233-4799 Physician's Surgical Procedure Disclosure and Patient s Consent TO THE PATIENT: You
More informationNorth York Endoscopy Instructions
North York Endoscopy Instructions IMPORTANT INFORMATION: Prior to taking the preparation, please read the details of the procedure, including the risks and benefits. If you agree to the procedure after
More informationLas Vegas Urogynecology
Las Vegas Urogynecology 7500 Smoke Ranch Road - #200 Las Vegas, NV 89128 Telephone: (702) 233-0727 Fax: (702) 233-4799 Physician's Surgical Procedure Disclosure and Patient s Consent TO THE PATIENT: You
More informationColonoscopy. patient information from your surgeon & SAGES. Colonoscopy 1
Colonoscopy patient information from your surgeon & SAGES Colonoscopy 1 Colonscopy About colonoscopy What is a colonoscopy? Colonoscopy is a procedure that enables your surgeon to examine the lining of
More information(516) Old Country Road, Suite 520 Fax: Mineola, NY Follow RefluxLI
COLONOSCOPY May Save Your Life! Colonoscopy can be a lifesaving procedure that can remove precancerous polyps, detect causes of bleeding and anemia, evaluate colitis and infections of the bowel, and assess
More informationEndoscopic Retrograde Cholangiopancreatography (ERCP)
Endoscopic Retrograde Cholangiopancreatography (ERCP) Medical Imaging and Treatment of the Bile and Pancreatic Ducts CIE-02718 Understanding ERCP Brochure Update_F.indd 1 7/11/18 9:51 A Minimally Invasive
More informationwho where symptoms? colon cancer facts affected? what
who Over 130,000 new cases diagnosed each year is Greater than 50,000 deaths annually attributable to colon cancer Second leading cause of cancer death in the U.S. Equal risk in men and women Women over
More informationDENTAL DIAGNOSIS AND TREATMENT
OFFICE POLICIES EXPECTED PAYMENT In order to keep our fees as low as possible we ask that co payments be paid at the time of service. For your conveniene an estimate for dental care will be prepared prior
More informationColonoscopy Altru HEALTH SYSTEM
Colonoscopy Altru HEALTH SYSTEM Colonoscopy Your colonoscopy is scheduled at Altru Clinic Ambulatory Procedure Center, waiting room 4-South on (date) Arrival time: Procedure time: This pamphlet has been
More informationUpper Gastrointestinal Endoscopy -Open Access
Upper Gastrointestinal Endoscopy - Open Access Facility:... A. INTERPRETER / CULTURAL NEEDS An Interpreter Service is required? Yes No If Yes, is a qualified Interpreter present? Yes No A Cultural Support
More informationNORTH YORK ENDOSCOPY CENTER Dr. K. JeeJeebhoy
Colonoscopy Instructions IMPORTANT INFORMATION: Prior to taking the preparation, please read the details of the procedure, including the risks and benefits. If you agree to the procedure after reading
More informationColonoscopy Explained
Colonoscopy Explained Your doctor has recommended that you have a medical procedure called a colonoscopy to evaluate or treat your condition. This brochure will help you understand how a colonoscopy can
More informationEndoscopic Mucosal Resection (EMR) & Endoscopic Submucosal Dissection (ESD)
Endoscopic Mucosal Resection (EMR) & Endoscopic Submucosal Dissection (ESD) Minimally Invasive Polyp Removal IE-02700-Understanding EMR and ESD Brochure_R3.indd 1 Occasionally, a polyp that infiltrates
More informationP R E S E N T S Dr. Mufa T. Ghadiali is skilled in all aspects of General Surgery. His General Surgery Services include: General Surgery Advanced Laparoscopic Surgery Surgical Oncology Gastrointestinal
More informationCOLONOSCOPY SUPPLIES YOU WILL NEED TO GET... PREP INSTRUCTIONS Instructions for prior to your procedure. A Partner for Lifelong Health
COLONOSCOPY SUPPLIES YOU WILL NEED TO GET... You will not need a prescription for any of these items. One 10 oz bottle of Magnesium Citrate. Buy the GREEN or CLEAR bottle - NOT the red cherry flavor. If
More informationI,, hereby authorize Dr. and any associates or assistants the doctor deems appropriate, to perform removal of the adjustable gastric band surgery.
INFORMED CONSENT FOR LAPAROSCOPIC ADJUSTABLE BAND REMOVAL PROCEDURE It is very important to [insert physician, practice name] that you understand and consent to the treatment your doctor is rendering and
More informationFlexible Sigmoidoscopy
Flexible Sigmoidoscopy Information Sheet Introduction You have been advised by your GP or hospital doctor to have an investigation known as a flexible sigmoidoscopy. Why do I need to have a flexible sigmoidoscopy?
More informationGary M. Annunziata, D.O., F.A.C.P. / Anh T. Duong, M.D. / Jonathan C. Lin, M.D., MPH Phone- (760) Fax- (760)
Gary M. Annunziata, D.O., F.A.C.P. / Anh T. Duong, M.D. / Jonathan C. Lin, M.D., MPH Phone- (760) 321-2500 Fax- (760) 321-5720 Preparation for EGD and/or PEG Placement Patient Name- Procedure Date and
More informationGary M. Annunziata, D.O., F.A.C.P. / Anh T. Duong, M.D. / Jonathan C. Lin, M.D., MPH Phone- (760) Fax- (760) Preparation for ERCP
Gary M. Annunziata, D.O., F.A.C.P. / Anh T. Duong, M.D. / Jonathan C. Lin, M.D., MPH Phone- (760) 321-2500 Fax- (760) 321-5720 Preparation for ERCP Patient Name- Procedure Date and Time- Please do not
More informationTrans-catheter aortic valve implantation (TAVI) work up
Trans-catheter aortic valve implantation (TAVI) work up You have been referred for an assessment known as a TAVI work up because you have been diagnosed with aortic stenosis. This factsheet explains the
More informationStretching of the corners of the mouth that may lead to cracking or bruising.
INFORMED CONSENT FOR REMOVAL OF CYST OR TUMOR Practice Administrator 9450 E Ironwood Square Dr. Scottsdale, AZ 85258 Phone: (480) 551-0581 Fax: (480) 551-0585 www.anewbeautifulyou.com Patient s Name Please
More informationEndoscopic Ultrasonography (EUS) Medical Imaging of the Digestive Tract and Internal Organs
Endoscopic Ultrasonography (EUS) Medical Imaging of the Digestive Tract and Internal Organs More Detailed Pictures for Better Diagnoses Endoscopic ultrasonography allows your doctor to examine your stomach
More informationUMC HEALTH SYSTEM Lubbock, Texas :
Consent for Commonly Performed Procedures in the Adult Critical Care Units I, the undersigned, understand that the adult intensive and intermediate care units ( critical care units ) are places where seriously
More informationKAROL A. GUTOWSKI, MD, FACS AESTHETIC SURGERY CERTIFIED BY THE AMERICAN BOARD OF PLASTIC SURGERY MEMBER AMERICAN SOCIETY OF PLASTIC SURGEONS
INFORMED CONSENT FOR SKIN LESION AND SOFT TISSUE MASS REMOVAL WITH PATHOLOGY EVALUATION WITHOUT PATHOLOGY EVALUATION PLEASE REVIEW AND BRING WITH YOU ON THE DAY OF YOUR PROCEDURE PATIENT NAME KAROL A.
More informationINFORMED CONSENT FOR SLEEVE GASTRECTOMY
INFORMED CONSENT FOR SLEEVE GASTRECTOMY This informed consent document has been prepared to help inform you about your Sleeve Gastrectomy including the risks and benefits, as well as alternative treatments.
More informationADVANCE MEDICAL DIRECTIVE OF
ADVANCE MEDICAL DIRECTIVE OF This form expresses my specific medical s in case illness prevents me from communicating them directly. My apply both to the illnesses described and to any other situations
More informationPENNANT HILLS DAY ENDOSCOPY CENTRE 10 RAMSAY ROAD
PENNANT HILLS DAY ENDOSCOPY CENTRE 10 RAMSAY ROAD Licence No. DC 018 PENNANT HILLS, 2120 Provider No. 657211 A www.pennanthillsendoscopy.com.au TELEPHONE: 98752311 FAX: 99809300 Preparation for colonoscopy
More informationWhy Choose Wudassie Diagnostic Center for GI service? Ease of Use: One Location: Reduced Cross-Infection: Focus on the Patient: Reduced Cost:
Why Choose Wudassie Diagnostic Center for GI service? In our center, patients find that the process much more convenient, as well as more personal. Our center offers a relaxed environment with medical
More informationP R E S E N T S Dr. Mufa T. Ghadiali is skilled in all aspects of General Surgery. His General Surgery Services include: General Surgery Advanced Laparoscopic Surgery Surgical Oncology Gastrointestinal
More informationCHOLECYSTECTOMY CONSENT FORM
1 of 6 Patient Name: I, have been asked to carefully read all of the (name of patient or substitute decision-maker) information contained in this consent form and to consent to the procedure described
More informationWhat Is an Endoscopic Ultrasound (EUS)?
ENDOSCOPIC ULTRASOUND (EUS) What Is an Endoscopic Ultrasound (EUS)? An endoscopic ultrasound (EUS) is a specialized procedure that blends: Endoscopy use of a scope to look at the inside lining of the gastrointestinal
More informationINFORMED CONSENT FOR GASTRIC BALLOON INSERTION
INFORMED CONSENT FOR GASTRIC BALLOON INSERTION This informed consent document has been prepared to help inform you about the Gastric Balloon Insertion procedure including the risks and benefits, as well
More informationHaving a therapeutic gastroscopy with oesophageal dilatation
Please telephone the Endoscopy Unit with regards information contained within this leaflet. A member of the nursing team will be glad to advise you. For all general enquiries please use the following contact
More informationCONSENT FOR FACE-LIFT SURGERY (RHYTIDECTOMY)
CONSENT FOR FACE-LIFT SURGERY (RHYTIDECTOMY) Patient s Name Date Please initial each paragraph after reading. If you have any questions, please ask your doctor BEFORE initialing. I have been informed that
More informationPlease inform us of any of the following;
COLONOSCOPY You have been advised by your doctor to have this test. This information pamphlet will help you understand this procedure and the preparation required. Colonoscopy is a visual examination of
More informationFecal microbial transplantation
Version 09/16 Consent Form For Fecal microbial transplantation Fecal transplant is an operation in which liquid produced from a healthy human being (as per a survey questionnaire and blood and feces tests)
More informationHEALTH SYSTEM UPPER ENDOSCOPY
Altru HEALTH SYSTEM UPPER ENDOSCOPY It is important to read these instructions upon receiving. Please review the Preparation instructions in the back of this booklet for important information regarding
More informationGastroscopy Instructions
Patient information Gastroscopy Instructions i Important pre operative information for all patients. Golden Jubilee National Hospital Agamemnon Street Clydebank, G81 4DY (: 0141 951 5000 www.nhsgoldenjubilee.co.uk
More informationPlease check appropriate box: Right Left Bilateral Not Applicable
Patient Label Here UNIVERSITY MEDICAL CENTER DISCLOSURE AND CONSENT - MEDICAL AND SURGICAL PROCEDURES TO THE PATIENT: You have the right as a patient to be informed about your condition and the recommended
More informationCOLONOSCOPY INFORMATION HANDOUT YOUR APPOINTMENT DETAILS ARE AS FOLLOWS:
DR LLOYD DORRINGTON MB BS (QLD) FRACP DR OLGA ELLISON MB BS (SA) FRACP Suite 3, Brockway House 82-86 Queen Street Southport QLD 4215 Ph: 07 5591 4455 Fax: 07 5591 4077 Email: office@dorringtons.com.au
More informationEGD (Esophagogastroduodenoscopy) or Upper Gastrointestinal Endoscopy Exam
Louis N. Aurisicchio, MD Georgia M. Close, MD Parantap Gupta, MD Robert Mendelsohn, MD Roxan F. Saidi, MD Harvey J. Rosenberg, MD Gastroenterologists Putnam Hospital Center 672 Stoneleigh Avenue Carmel,
More informationCoronary Angioplasty and Stenting PROCEDURAL CONSENT FORM. A. Interpreter / cultural needs. B. Condition and treatment
(Affix identification label here) URN: Coronary Angioplasty and Stenting Facility:... Family name: Given name(s): Address: Date of birth: Sex: M F I A. Interpreter / cultural needs An Interpreter Service
More informationBREAST REDUCTION. Based on my discussions with Dr Gutowski, I understand and agree to the following:
INFORMED CONSENT FOR BREAST REDUCTION PLEASE REVIEW AND BRING WITH YOU ON THE DAY OF YOUR PROCEDURE PATIENT NAME Based on my discussions with Dr Gutowski, I understand and agree to the following: Dr. Gutowski
More informationColon Cancer Surgery
Colon Cancer Surgery Introduction Colon cancer is a life-threatening condition that affects thousands of people. Doctors usually recommend surgery for the removal of colon cancer. If your doctor recommends
More informationPatient information/declaration of consent for ERCP (imaging of the bile ducts and pancreas with a contrast substance)
- 1 - Patient information/declaration of consent for ERCP (imaging of the bile ducts and pancreas with a contrast substance) Declaration of informed consent provided by: Date: Dear Patient, Please be so
More informationCONSENT FOR TWO-STAGE OSSEOUSINTEGRATED IMPLANT WITH SINUS-LIFT/BONE GRAFTING PROCEDURE
CONSENT FOR TWO-STAGE OSSEOUSINTEGRATED IMPLANT WITH SINUS-LIFT/BONE Page 1 of 4 Patient s Name Date Please initial each paragraph after reading. If you have any questions, please ask your doctor before
More informationColonoscopy and Flexible Sigmoidoscopy Instructions
Patient information Colonoscopy and Flexible Sigmoidoscopy Instructions i Important pre operative information for all colonoscopy and flexible sigmoidoscopy patients. Golden Jubilee National Hospital Agamemnon
More informationColonoscopy. Soon you will undergo a colonoscopy. The doctor will examine the inside of your colon with a sort of camera that is inserted in the anus.
Gynaecology - Obstetrics - Senology - Urogynaecology Gastroenterology - Plastic and aesthetic surgery Physical therapist - Dietetics Alex Feldheimstraat 56 1930 Zaventem info@mirha.be Tel: 02/720 26 16
More informationKAROL A. GUTOWSKI, MD, FACS AESTHETIC SURGERY CERTIFIED BY THE AMERICAN BOARD OF PLASTIC SURGERY MEMBER AMERICAN SOCIETY OF PLASTIC SURGEONS
INFORMED CONSENT FOR EAR LOBE SURGERY PLEASE REVIEW AND BRING WITH YOU ON THE DAY OF YOUR PROCEDURE PATIENT NAME KAROL A. GUTOWSKI, MD, FACS AESTHETIC SURGERY CERTIFIED BY THE AMERICAN BOARD OF PLASTIC
More informationOTOPLASTY (EAR RESHAPING)
INFORMED CONSENT FOR OTOPLASTY (EAR RESHAPING) PLEASE REVIEW AND BRING WITH YOU ON THE DAY OF YOUR PROCEDURE PATIENT NAME KAROL A. GUTOWSKI, MD, FACS AESTHETIC SURGERY CERTIFIED BY THE AMERICAN BOARD OF
More informationCary Gastroenterology Associates Colonoscopy Consent Form
Cary Gastroenterology Associates Colonoscopy Consent Form Your physician has requested that you undergo a procedure called Colonoscopy. Colonoscopy is a procedure that enables the physician to see inside
More informationMaking a Decision about Colon Cancer Screening. Copyright 2010 University of North Carolina All Rights Reserved.
Making a Decision about Colon Cancer Screening Introduction The American Cancer Society recommends older adults age 75 and over decide whether or not to get screened for (cancer of your bowels). This Decision
More informationWhat is a Gastroscopy?
GASTROSCOPY INFORMATION SHEET PLEASE READ THIS, SIGN THE 2 CONSENT FORMS ATTACHED AND BRING THESE WITH YOU ON THE DAY OF YOUR PROCEDURE Why do I need to have a Gastroscopy? You have been advised to undergo
More informationColon Investigation. Flexible Sigmoidoscopy
Colon Investigation Flexible Sigmoidoscopy What is a flexible sigmoidoscopy? Flexible sigmoidoscopy is a frequently performed test to investigate the lower part of the bowel. This is an endoscopic test
More informationSummary of Important Points Please note that the time given to you is your arrival time and not the time of your procedure. The time taken to perform
Summary of Important Points Please note that the time given to you is your arrival time and not the time of your procedure. The time taken to perform endoscopy procedures vary and emergency patients sometimes
More informationColonoscopy Patient Information
Colonoscopy Patient Information Introduction Your doctor has recommended that you have a colonoscopy. However, it is your decision whether or not to go ahead with the procedure. This leaflet gives you
More informationCONSENT FOR TWO-STAGE OSSEOUSINTEGRATED IMPLANT WITH SINUS-LIFT/BONE GRAFTING PROCEDURE Page 1 of 5
SINUS-LIFT/BONE GRAFTING PROCEDURE Page 1 of 5 Patient s Name Please initial each paragraph after reading. If you have any questions, please ask your doctor BEFORE initialing. You have the right to be
More informationPATIENT INFORMATION FROM YOUR SURGEON & SAGES. Laparoscopic Colon Resection
Patient Information published on: 03/2004 by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) PATIENT INFORMATION FROM YOUR SURGEON & SAGES Laparoscopic Colon Resection About Conventional
More informationWhat can you expect after your ERCP?
ERCP Explained and respond to bed rest, pain relief and fasting to rest the gut with the patient needing to stay in hospital for only a few days. Some patients develop severe pancreatitis and may require
More informationArmidale General Surgery. Patient Information regarding Colonoscopy
Armidale General Surgery Patient Information regarding Colonoscopy Colonoscopy is an examination of the inner lining of the large bowel (colon and rectum) using a flexible telescopic tube (about the diameter
More informationConsent for NIL (Tickle Liposuction) and BodyTite
Consent for NIL (Tickle Liposuction) and BodyTite I authorize a Zelko Aesthetic surgeon to perform Liposuction on me using the Nutational Infrasonic Liposuction (NIL) (aka Tickle Lipo) to facilitate the
More informationPatient Name: MRN: DOB: Treatment Location:
Page 1 of 5 I. TO (Required) This Section is required to be completed by all patients who undergo kidney transplant surgery. I hereby consent to and authorize Dr. and his/her assistant(s), including supervised
More informationColonoscopy Preparation
D i g e s t i v e D i s e a s e C e n t e r Gastroenterology and Advanced Endoscopy Phone (718) 270-4772 Fax (718) 270-7201 www.downstategi.org Colonoscopy Preparation YOur EXAM IS SCHEDuLED FOr: Monday
More informationGastroscopy instructions
Golden Jubilee National Hospital NHS National Waiting Times Centre Gastroscopy instructions Pre operative patient information guide Agamemnon Street Clydebank, G81 4DY (: 0141 951 5000 www.nhsgoldenjubilee.co.uk
More informationOesophagogastro. duodenoscopy (OGD)
Oesophagogastro duodenoscopy (OGD) Information Sheet, Appointment Details and Postal Consent Form Please bring this booklet with you Your Appointment: Date & Day Time Place Daycase & Endoscopy Unit Stamford
More informationFlexible Sigmoidoscopy Information and Preparation
Flexible Sigmoidoscopy Information and Preparation Flexible Sigmoidoscopy Information and Preparation **If for any reason you need to cancel your scheduled appointment Barrie Endoscopy requires a minimum
More informationWhat is a Colonoscopy?
What is a Colonoscopy? A colonoscopy is a test to look inside your colon. A colonoscopy is done by a gastroenterologist, a doctor trained in looking at the gastrointestinal (GI) tract. The main tool used
More informationPatient Gastroscopy Package
2014 Patient Gastroscopy Package BARRIE ENDOSCOPY 5 Quarry Ridge Road, Barrie, Ontario- L4M 7G1 General Patient Information THE FOLLOWING INFORMATION PERTAINS TO ALL PATIENTS HAVING PROCEDURES AT BARRIE
More informationPhone [850] Fax [850] Web Send s to: Search Millseye to download App Page 1 of 5
YAG PC (Posterior Capsulotomy) Consent Form 1) I,, hereby authorize: David M. Mills, MD, FACS and/or whomever he may designate as his assistant(s), to perform upon myself the following operation(s): YAG
More informationWhat is an Upper GI Endoscopy?
What is an Upper GI Endoscopy? An upper GI endoscopy is a test your doctor does to see inside part of your digestive system. Your doctor will look at the inside of your esophagus (the tube that links your
More informationTherapeutic gastroscopy Oesophago-gastro duodenoscopy (OGD) with stent insertion performed at the Royal Berkshire Hospital
Therapeutic gastroscopy Oesophago-gastro duodenoscopy (OGD) with stent insertion performed at the Royal Berkshire Hospital Information and consent form Please bring this booklet with you Introduction You
More informationTranscatheter Aortic Valve Implantation Procedure (TAVI)
Page 1 of 5 Procedure (TAVI) Introduction Aortic stenosis (AS) is a common heart valve problem associated with heart failure and death. Surgical valve repair or replacement is recommended if AS patients
More informationNames and ages of other children in family School Grade. Employer Phone
Robert D. Elliott, DMD, MS Cary Pediatric Dentistry Julie R. Molina, DDS, MS 540 New Waverly Place Suite 300 Cary, NC 27518 Telephone: (919) 852-1322 FAX: (919) 852-1230 Demographic Information Patient
More informationHaving an ERCP (endoscopic retrograde cholangio pancreatogram)
Having an ERCP (endoscopic retrograde cholangio pancreatogram) The aim of this information sheet is to help answer some of the questions you may have about having an ERCP. It explains what it is, why it
More informationDeep Enteroscopy Methods to Diagnose Small Bowel IBD
Deep Enteroscopy Methods to Diagnose Small Bowel IBD Name: Institution: Peter Draganov University of Florida, Gainesville, FL Overview Types of enteroscopy Enteroscopy equipment Enetoscopy do and don'ts
More informationColorectal Cancer Screening
Scan for mobile link. Colorectal Cancer Screening What is colorectal cancer screening? Screening examinations are tests performed to identify disease in individuals who lack any signs or symptoms. The
More informationWOMEN & INFANTS HOSPITAL Providence, RI CONSENT FOR IVF WITH EMBRYO TRANSFER
*40639* 40639 WOMEN & INFANTS HOSPITAL Providence, RI 02905 CONSENT FOR IVF WITH EMBRYO TRANSFER I have requested treatment by the physicians and (Print Patient s name) staff of the Women & Infants Fertility
More informationP R E S E N T S Dr. Mufa T. Ghadiali is skilled in all aspects of General Surgery. His General Surgery Services include: General Surgery Advanced Laparoscopic Surgery Surgical Oncology Gastrointestinal
More informationCOLONOSCOPY AND GASTROSCOPY INFORMATION HANDOUT
DR LLOYD DORRINGTON MB BS (QLD) FRACP DR OLGA ELLISON MB BS (SA) FRACP Suite 3, Brockway House 82-86 Queen Street Southport QLD 4215 Ph: 07 5591 4455 Fax: 07 5591 4077 Email: office@dorringtons.com.au
More informationPatient Registration. First Name: Last Name: Middle Initial: Address: City, State, Zip: First Name: Last Name: Middle Initial:
Patient Registration First Name: Last Name: Middle Initial: Preferred Name: DOB: Sex: Male Female Address: City, State, Zip: Home#: Cell#: Soc. Sec. #: Referred By: Previous Dentist: Responsible Party
More informationPlease arrive at The Corvallis Clinic Surgery Center AM / PM
Name: Please arrive at The Corvallis Clinic Surgery Center on @ AM / PM **You must be accompanied by an adult family member/friend, over the age of 18, who can take responsibility for you and sign your
More informationPolyps in the bowel. Endoscopy Department. Patient information leaflet
Polyps in the bowel Endoscopy Department Patient information leaflet You will only be given this leaflet if you have been diagnosed with polyps in the bowel. The information below outlines the condition,
More informationSOD (Sphincter of Oddi Dysfunction)
SOD (Sphincter of Oddi Dysfunction) SOD refers to the mechanical malfunctioning of the Sphincter of Oddi, which is the valve muscle that regulates the flow of bile and pancreatic juice into the duodenum.
More informationFY 2017 MCRCEDP Procedure Code Reference Chart
45378-53 45380 45381 45382 45384 45385 48388 45390 ; Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon
More informationUndergoing a gastroscopy with colonoscopy
Page 1 of 9 Undergoing a gastroscopy with colonoscopy Introduction You have been advised to have a gastroscopy and colonoscopy. Other names for these tests are an endoscopy, and you may hear staff refer
More informationUnderstanding Gastroscopy (Upper GI Endoscopy)
Summary of important information A Gastroscopy is a safe procedure and a very good way to investigate your symptoms. Risks and complications are rare and the benefits outweigh the risks. However, it is
More informationINFORMED CONSENT FORM FOR SEPTOPLASTY(OPERATION FOR THE DEVIATED NASAL SEPTUM)
Patient Name-Surname: Sex: F M Patient No: Date of Birth: Father s Name: ID Card No: Dear Patient / Guardian It is your incontestable right to be informed about all medical/surgical procedures suggested
More informationINFORMED CONSENT-RHINOPLASTY SURGERY
INFORMED CONSENT-RHINOPLASTY SURGERY 2000 American Society of Plastic Surgeons. Purchasers of the Patient Consultation Resource Book are given a limited license to modify documents contained herein and
More informationFlexible Sigmoidoscopy Patient Information
Flexible Sigmoidoscopy Patient Information Introduction Your doctor has recommended that you have a flexible sigmoidoscopy. However, it is your decision whether or not to go ahead with the test. This leaflet
More informationINFORMED CONSENT REDUCTION MAMMAPLASTY
INFORMED CONSENT REDUCTION MAMMAPLASTY INSTRUCTIONS This is an informed-consent document that has been prepared to help your plastic surgeon inform you abut reduction mammaplasty surgery, its risks, and
More informationPREPARING FOR REFLUX TESTING. Bravo Reflux Testing System. A simple way to evaluate your gastroesophageal reflux symptoms
PREPARING FOR REFLUX TESTING Bravo Reflux Testing System A simple way to evaluate your gastroesophageal reflux symptoms HOW IT WORKS The test involves a miniature ph capsule, which is approximately the
More informationPreparing For Colonoscopy
Preparing For Colonoscopy COLONOSCOPY OVERVIEW A colonoscopy is an exam of the lower part of the gastrointestinal tract, which is called the colon or large intestine (bowel). Colonoscopy is a safe procedure
More informationBilling Guideline. Subject: Colorectal Cancer Screening Exams (Invasive Procedures) Effective Date: 1/1/14 Last revision effective 4/16
Billing Guideline Subject: Colorectal Cancer Screening Exams (Invasive Procedures) Effective Date: 1/1/14 Last revision effective 4/16 Florida Hospital Care Advantage plans include full coverage of in-network
More informationWOMEN & INFANTS HOSPITAL Providence, RI CONSENT FOR IN VITRO FERTILIZATION USING A GESTATIONAL CARRIER (PATIENT/INTENDED PARENTS) 1.
*40675* 40675 MR-838 (9-2017) WOMEN & INFANTS HOSPITAL Providence, RI 02905 CONSENT FOR IN VITRO FERTILIZATION USING A GESTATIONAL CARRIER (PATIENT/INTENDED PARENTS) 1. I, and (Print Patient s name) (Print
More information