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Download gastroenterology consultants, ltd. nevada endoscopy management
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GASTROENTEROLOGY CONSULTANTS, LTD.
NEVADA ENDOSCOPY MANAGEMENT, INC.
RENO ENDOSCOPY CENTER, LLC
CARSON ENDOSCOPY CENTER, LLC
SOUTH MEADOWS ENDOSCOPY CENTER, LLC
Fleets Phospho-soda, OsmoPrep, and Visicol Disclaimer
On May 5, 2006 the Federal Drug Agency put out a warning that bowel cleansing preparations
known as oral sodium phosphate products (OSP) can rarely cause permanent kidney failure
requiring hemodialysis. Documented cases included 21 patients who used an OSP solution
(such as Fleet Phospho-soda and Fleet ACCU-PREP) and one patient who used OSP tablets
(Visicol). It hasn’t been reported with OsmoPrep.
You may be at increased risk of this severe adverse reaction if:
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You are older than 50.
You have underlying kidney disease from diabetes, hypertension, or other causes.
You have congestive heart failure or cirrhosis.
You take medications that affect kidney circulation such as various blood pressure
medications and possibly non-steroidal anti-inflammatory drugs (e.g. Motrin, Advil, etc.).
You take other sodium phosphate products for constipation around the time of your
preparation.
You are dehydrated before, during or immediately after your bowel preparation.
If you have any of the above risk factors, please notify us so we can offer alternative preparation.
For those patients who cannot tolerate the alternative bowel preparations and need to use an
OSP, they can reduce their risk of kidney failure by maintaining good hydration before, during, and
after the preparation.
In signing this form, you acknowledge that
• You have been notified of the risks and offered alternatives but decline; preferring this
preparation, understanding the risks.
• Reviewed the information provided above with all of your questions being answered.
• If you need additional information, please do not sign this form; discuss the matter further with
your provider.
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Patient Name (print)
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Date
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Patient Signature
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Date
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Employee Witness Signature
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Date
Pt DOB: {PATIENT.DATEOFBIRTH}
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Doctor:
