Third Avenue Gastroenterology, P.C.
1317 Third Avenue, 9th Floor
New York, N.Y. 10021
CONSENT FORM FOR FLEXIBLE SIGMOIDOSCOPY
PATIENT’S NAME:
DATE:
I hereby authorize Dr.
to perform upon me the following endoscopic procedure(s) and/or treatment(s):
Flexible sigmoidoscopy with or without biopsy, polypectomy, control of bleeding, for the following indications:
INFORMATION REGARDING GASTROINTESTINAL ENDOSCOPY
Direct visualization of the digestive tract with lighted instruments is referred to as gastrointestinal endoscopy.
Your physician has advised you of your need to have this type of examination. The following information
describes the reasons for, and possible risks of, these procedures.
At the time of your examination, a flexible tube will be inserted into the rectum and the inside lining of the left
side of the colon (large bowel) will be inspected thoroughly. If an abnormality is seen or suspected, a small
portion of tissue (biopsy) may be removed for microscopic study. Small growths (polyps) can frequently be
completely removed (polypectomy). Polypectomies are done using a wire loop and electric current Treatment
may be performed to stop bleeding and pictures may be taken.
RISKS
The following are the principal risks of a flexible sigmoidoscopy:
1. Injury to the lining of the digestive tract by the instrument that may result in perforation of the wall
and leakage into body cavities. If this occurs, surgical operation to close the leak and drain the region
is often necessary.
2. Bleeding may be a complication of biopsy or polypectomy. Management of this complication may
consist of careful observation or repealing the procedure or may require blood transfusions or possibly
a surgical operation.
3. Medications may be given into the vein to improve comfort, allay anxiety and decrease movement
durirg the procedure. I understand that the use and type of anesthesia, sedatives or analgesics will be
explained to me by the Anesthesiologist before the procedure or by the physician administering the
medication prior to the procedure/treatment. The risks, benefits and alternatives to their use will also
be explained to me. A medication given in the vein, may cause vein irritation (phlebitis) or pain, allergic
reaction, cardiorespiratory depression or possible arrest.
4. Rectal irritation may occur alter the procedure.
Other risks include drug reactions and complications related to other diseases you may have. All these
complications are possible, but occur with very low frequency. Your physician will discuss this
frequency with you, if you wish.
The purpose of the endoscopic procedure(s) and/or treatment(s) has/have been explained to me and I have
also been informed of the:
1. expected benefits and possible complications
2. associated discomforts and risks, including the risk that such treatment may not improve my condition
3. possible or likely results of the proposed procedure/treatment
4. possible alternatives to the proposed procedure/treatment, including no procedure/treatment
5. prognosis if no procedure/treatment is received
ADVANCED DIRECTIVES
In the event a life-threatening emergency occurs, such as respiratory or cardiac arrest, the Third Avenue
Gastroenterology staff will implement the following on ALL patients:
1. Perform emergency procedures as necessary, including cardiopulmonary resuscitation (CPR) to stabilize
patient.
2. Upon your physician’s order, we will transfer you to an acute healthcare facility (hospital) where your
physician and family can make an informed decision regarding your well-being.
3. Upon transfer to the acute care facility (hospital), we will send copies of all records and documentation,
including copies of your Advanced Directives if you have provided us with a copy.
If an unforeseen complication arises during this procedure calling for additional procedures, operations or
medications, futher request and authorize him/her to do whatever he/she deems advisable in my interest.
I am aware that the practice of medicine and surgery is not an exact science, and I acknowledge that no
guarantees have been made to me concerning the results of the procedure.
I certify that I have read, fully understand, and consent to the above procedure(s), that the explanations
referred to above have been made, and that all blanks and statements requiring insertion or completion were
filled in and inapplicable paragraphs, if any, were stricken (and initialed by both me and my physician) before I
signed this consent.
Patient/Healthcare Agent:
Witness:
Signature
Signature of Patient
or Health Care Representative
Print Name of Patient
Relationship to Patient
Date
Interpreter:
Physician Certification
I hereby certify that the nature, purpose, benefits, risks of, and alternatives to the endoscopy
procedure(s) and/or treatment(s) have been explained to the patient. Any and all questions have been
answered. I believe that the patient/healthcare agent fully understands what has been explained.
Physician:
Signature
Print Name
Date