ENDOSCOPY CONSENT FORM
NAME: _____________
PROCEDURE DATE: __________PROCEDURE TIME: ______________
INITIAL HERE
1. I_______________________________(patient or guardian) give consent for Dr.___________________or ___________
his/her associates to perform an endoscopy with possible biopsy, dilation, removal of polyp(s) with
possible coagulation/ injection therapy of blood vessels or tissue, and control of bleeding if necessary.
2. I understand this procedure involves the passage of a digital optic instrument through the mouth to allow ___________
the physician to visualize the interior of the esophagus, stomach, and part of the small intestine. Sedation
and pain-relieving medications may be given to minimize discomfort and relax me for the procedure.
These medications may cause localized irritation and/or a drug reaction. I understand that with
anesthesia/sedation for this procedure I will not be able to drive the remainder of the day and I should not
have plans after the procedure. I understand that I MUST HAVE A DRIVER take me home.
3. I understand the reasons for the procedure which have been adequately explained to me by my physician. I ___________
understand I may call the office where I see my physician with any questions about the preparation or
procedure. I have had ample opportunity to ask questions before signing this consent.
4. There are some RISKS that are related to this procedure and they include, but are not limited to: ___________
a. Allergic or adverse reaction to the sedative or other medications administered.
b. Infection or irritation at the IV site.
c. Perforation or tearing of the wall of the esophagus, stomach, or small intestine is a known, but rare,
complicationwhich can occur at a rate of 1 per every 5,000-10,000 endoscopies.
d. Bleeding, usually after a polyp removal, can occur at a rate of 1 per 1,000 endoscopies and
continues up to four weeks after a polyp is removed.
e. Other extremely rare, but serious or possibly fatal risks include: difficulty breathing, aspiration (to
swallow vomitinto the lungs), heart attack, arrhythmia (change in heart rhythm), and stroke.
f. These complications, should they occur, may require surgery, hospitalization, repeat endoscopy,
and/or a blood transfusion.
g. Polyps, especially small ones, can be missed, and in rare cases, a cancer can be missed.
Endoscopy does not guarantee that you will not develop a cancer of the esophagus, stomach, or
small intestine. However, endoscopy is the best test to look for these findings.
5. I understand that there are no guarantees regarding the results of this procedure. Alternative options as ___________
deemed medically relevant have been discussed and may include radiologic imaging tests. I understand
that these tests have their own limitations and benefits.
6. I have read and fully understand this consent form and understand that I should not sign if all of my ___________
questions have not been answered to my satisfaction or if I do not understand any of the words or terms
used in this form
If you have any questions as to the risks or hazards of the proposed procedure or treatment, ask your physician now, before
signing this consent form. Do not sign unless you have thoroughly read and thoroughly understand this form.
HCM City, Date……/…….../……..
Patient or guardian
Signature and full name ______________________________
SAI GON SPECIALISTS CENTRE: 245 Phan Xich Long Street, Ward 2, Phu Nhuan District, Ho Chi Minh City; Tel: (028)35355460; Hotline: 0901840678
Email: [email protected]; Working hours: 7 AM – 11:30 AM; 12:30 PM– 4:00 PM
