STAR ENDOSCOPY
1081 Carling Ave,
Suite 207
Ottawa, Ontario
Phone: 613-729-3179
Your Gastroscopy (upper endoscopy)
appointment is booked for:
Date: ______________ Arrival Time: __________
With Dr.____________
Office hours: 7:30 am to 4 pm.
Patient pick up have to be in the office by 4 p.m.
**You MUST read these instructions at least 1
week prior to appointment to be properly
prepared**
PREPARATION:
12 hours before the appointment;
-Stop taking any food, you may continue with clear fluids only.
-You may take clear fluids up to 6 hours before the examination.
Clear fluids allowed: Water, Clear fruit juice (apple, grape, cranberry,
cranapple etc), chicken broth, beef broth, vegetable broth, Jello, Soft
drinks, Tea or Coffee, Popsicles, Clear Gatorade.
NO SOLID FOOD, MILK OR MILK PRODUCTS
On the day of the appointment:
-6 hours before your appointment time STOP TAKING ANY FLUIDS. INCLUDING
WATER.
What can I expect during the procedure?
An endoscope is a long flexible tube that is thinner than most food that you swallow. If
is passed through the mouth and back of the throat into the upper digestive tract and
allows the physician to examine the lining of the esophagus, stomach, and duodenum.
The tube will not interfere with your breathing. The procedure usually takes only a few
minutes. If you are very anxious you may request mild sedation to help you relax, Major
effects of the sedation wears off in about 1hour. Endoscopy is safe and is associated with
very low risk when performed by physicians who have been trained and are experienced
in this procedure. Complications can occur but are rare. Bleeding may occur from the
site of biopsy or polyp removal. It is usually minimal but rarely may require transfusions
or surgery.
After your Gastroscopy:
-You will remain in the recovery room until the doctor discharges you.
-You will be able to resume your normal diet after the procedure unless you are
instructed otherwise
Things to know ahead of time:
1) You MUST make arrangements to have someone drive you home after your
procedure if you have sedation as you will not be allowed to drive till the next
day. If you use public transit or a taxi, you MUST be accompanied. Again for
safety reasons, the person MUST meet you inside the clinic after the procedure
as you cannot leave the premises on your own. NO EXCEPTIONS!
2) Your approximate stay will be 1.5 hours from your arrival time. We can call your
ride so they do not have to sit and wait.
3) No Show Fee of $100 (not covered by OHIP) will be billed to the patient for any
and all missed appointments. 2 business days notice is required to reschedule all
procedure appointments otherwise the No Show fee will be in effect. The office is
closed on holidays so please still allow 2 business days to reschedule
appointments.
4) We offer patients of the clinic an option of paying for uninsured services by way of
a block fee or individually. We have attached a form that lists and explains what
are uninsured services and the cost, if paying for them individually. There is no
requirement that patients pay the block fee, they may pay for uninsured services
individually for those uninsured services they wish to receive.
The block fee is $60 for a 12 month period. This fee is not covered by OHIP. Some
insurance companies may reimburse this fee while others may not.
This fee is payable when you check in. We only accept cash, debit, Visa and
MasterCard for payment of uninsured services.
If you have any questions about these fees, please call our office prior to your
appointment.
For more information on block fees please visit the College of Physicians of
Ontario website at www.cpso.on.ca under policies where you will find an
information sheet.
5) Please note that upper endoscopy procedures are fully insured by OHIP.
Precautions
-Iron Tablets: Discontinue 7 days prior.
-Anticoagulants: i.e.: Coumadin/warfarin/pradax. Check with your family doctor
that you can safely stop for 5 days prior and inform our office.
** An INR will need to be done the day before the procedure** (only if you are on
the above meds)
-If you are diabetic on tablets hold the a.m dose and bring with you. If on insulin
contact your family doctor about holding the a.m dose. You will be booked an
early morning appointment.
-Please take your medications for blood pressure, thyroid, and heart
conditions. You are only to stop Iron tablets, Coumadin/warfarin/pradax…no
other medications.
-If you have a heart valve replacement you will need IV antibiotics prior to
procedure. Please notify our office as soon as possible if this applies to you, as well
as any allergies to antibiotics. Antibiotics are for heart valve replacements only.
If you have sedation:
1. You will not be allowed to drive till the next day and you must have
someone drive you home following the procedure. NO
EXCEPTIONS
2. You may feel disoriented or forgetful due to the sedation for a short
time after the procedure.
UNINSURED SERVICES FEES
SERVICE
FEE
1.SEDATION AND/OR OTHER MEDICATIONS
$45.00
2. Telephone renewals of a prescription at the request of patient or patient’s
representative, where deemed appropriate by the prescribing physician.
$25.00 per
medication
3. Completion and transmission of various forms which are not covered by OHIP,
such as insurance sickness/disability and travel cancellation insurance forms.
$30.00 to
$100.00
4. Chart summaries, transfer of records, faxing and photocopying when care of patient
is being transferred at the request of patient or patient’s representative. Important
Note: a complete report concerning the procedure itself will be provided for free
of charge to your referring doctor.
$30.00
5. Return to work/school or sick notes
$35.00
6. Long distance phone calls.
$10.00
minimumcharge
$25.00
7. Email communications. Instructions sent by email are free of charge.
If you are unsure as to whether a service is uninsured, please ask clinic staff.
For more information about block fees please visit the CPSO website at www.cpso.on.ca
and look under policies.
Information regarding uninsured services:
You have the option to pay a fee of $60 block fee (which covers a period of
12 months)-or pay for each individual uninsured service (as listed on the
accompanying sheet.)
You can, within 7 days of paying, decide against paying the block fee and
instead decide to pay for each individual service separately. Please contact
our office to make arrangements to come in for the reimbursement within 7
days of your procedure date.
If you have any questions regarding the above please contact our clinic staff.
**PLEASE NOTE THAT OUR CANCELLATION FEE OF $100 IS
SEPARATE FROM THE ABOVE**
I understand the policies regarding uninsured services.
I agree to pay the Block Fee _____
I agree to pay individually for each uninsured service I request. ____
________________________________________________________
Signature
Date
PLEASE NOTE
THIS PAGE IS FOR EMBASSY, DIPLOMAT AND QUEBEC PATIENTS ONLY
EMBASSY, DIPLOMAT AND QUEBEC PATIENTS WILL BE REQUIRED TO PAY
FOR THEIR PROCEDURES UP FRONT. WE WILL PROVIDE QUEBEC PATIENTS
WITH AN OUT OF PROVINCE CLAIM THAT YOU CAN SUBMIT TO YOUR
HEALTH PLAN FOR REIMBURSEMENT. RECEIPTS WILL BE GIVEN.
METHODS OF PAYMENT:
DR. TAMBAY AND DR. SEKAR:
 CASH
 VISA
 MASTERCARD
 DEBIT
DR. DOUMIT, DR. DHALIWAL AND DR. SUTCLIFFE:
 CASH
 CHEQUE
CONSULTATION
FOLLOW UP
COLONOSCOPY RANGES FROM
GASTROSCOPY RANGES FROM
$157.00
$38.05
$200-$800
$200-$500
IF YOU HAVE ANY QUESTIONS REGARDING THE ABOVE, PLEASE CALL OUR
OFFICE AT 613-729-3179.
*PLEASE NOTE UNINSURED SERVICES INFORMATION IS ON PREVIOUS
PAGES.