Download Endovision consent form_ENGLISH

Tel: 514-595-3636
Fax: 514-788-2313
www.endovisionclinic.com
CONSENT FORM FOR COLONOSCOPY & ESOPHAGOGASTROSCOPY
TO THE PATIENT:
PLEASE READ CAREFULLY AND COMPLETE THIS CONSENT FORM
Section A. PATIENT INFORMATION/SURGERY TO BE PERFORMED / ATTENDING
PHYSICIAN
Please note that all personal information provided by the patient is confidential.
Confidentiality is maintained by Endovision Plus Inc and its staff in full compliance with
all
applicable laws.
Patient Name (Please print) _______________________________________
Patient Address (Please print) _________________________________________
Male ________ Female ___________
Patient Date of Birth________________
Age________________
Notification Contact or Person accompanying Patient__________________________
Please indicate whether any of the following situations apply to you. It is
Important that you check all that apply to you;
Cardiac pacemaker
___________
Ocular implant or cochlear implant
___________
Clip on a cerebral aneurysm
___________
Any other implant, prosthesis, rod, surgical clips, metal or other device, including
pins or clips. Please include any such items resulting from fracture, hip or knee
replacements. Please specify all such implants and/or devices:
_____________________________________________________________________________________
_____________________________________________________________________________________
Tel: 514-595-3636
Fax: 514-788-2313
www.endovisionclinic.com
Please indicate prior surgeries, if any __________________________________
Please indicate whether you are or may be pregnant and if so, how many
Weeks ____________________________________________________________________
Medications which you are currently taking ______________________________________
Known Allergies to Medications _________________________________________________
Other illnesses for which you are currently being treated ______________________________
PROCEDURE TO BE PERFORMED (check which will apply):
Colonoscopy _______
Esophagogastroscopy (Gastroscopy) __________
Date of procedure _________________
RAMQ _______________________________
Attending Physician ________________________________
Section B. THE NATURE OF THE PROCEDURE(S)
1. Colonoscopy is the direct visualization of the lining of the large intestine which
uses a long, flexible instrument with a tiny video camera. During inspection of the
lining, certain diagnostic or therapeutic interventions may be performed. A
sample of tissue may be taken (biopsy). A polyp may be removed
(polypectomy). Fluid may be obtained for analysis. Pictures will be taken during
your procedure.
2. Esophagogastroscopy (Gastroscopy) is the examination of the esophagus,
stomach and duodenum to look for ulcers, inflammation and areas of bleeding.
As with colonoscopy, the same diagnostic and therapeutic options can be
performed.
Section C. PRINCIPAL RISKS & COMPLICATIONS OF COLONOSCOPY &
GASTROSCOPY
PERFORATION – Passage of the instrument may result in a hole the wall of the
large bowel resulting in leakage of bowel contents into the body cavity. This is a very
rare occurrence ( 0.05% or 1 event per 2000 procedures). If this occurs, surgery to close
the opening will be required & you will be transported to a hospital facility.
Tel: 514-595-3636
Fax: 514-788-2313
www.endovisionclinic.com
BLEEDING – Bleeding, if it occurs, is usually a complication of biopsy or
polypectomy. The risk of bleeding following routine colonoscopy is 0.07% (7
events per 10,000 procedures) and following polypectomy it is 1.2% ( 1.2 events
per 100 procedures). Management consists of careful observation, transfusion
or, in rare circumstances, surgery.
MEDICATION PHLEBITIS – Medications used for sedation may irritate the vein into
which they are injected. This causes a red, painful swelling of the vein &
surrounding tissue. This may last up to several months, but will eventually go away.
Discomfort may be relieved with application of warm compresses.
RESPIRATORY DEPRESSION – The sedation used for this procedure may
occasionally lower respiratory rate. Supplementary oxygen may be necessary
until the sedation wears off.
OTHER POTENTIAL RISKS – Drug reactions, allergies and/or other existing illnesses: it
is possible to experience drug reactions and/or complications from other
diseases or chronic conditions you may already have. You must inform your
physician of any allergies or other existing medical problems of which you are
aware or for which you are being treated.
MODERATE SEDATION ADMINISTRATION
During the procedure, moderate sedation is administered to the patient. My
physician has reviewed the risks of sedation with me, and I have explained to the
physician any known allergies that I may have to such medications or adverse
reactions to such medications, which I may have experienced in the past. I
understand the risks as explained to me. I accept these risks and consent to the
administration of moderate sedation. I have arranged to have a responsible
person drive me home. I understand that impairment of full mental alertness may
persist for several hours following the administration of moderate sedation, and I
will avoid making decisions or taking part in activities which depend on my full
concentration or judgment during this time period.
Tel: 514-595-3636
Fax: 514-788-2313
www.endovisionclinic.com
Section D. ENDOVISION PLUS INC – Specific Information and Disclosure
The benefits and risks of undergoing colonoscopy and/or esophagogastroscopy
at an outpatient facility versus a hospital setting have been explained to me in
general terms, and I understand and accept the risks. I also understand and
accept that every surgical procedure, however minor or therapeutic, is an
invasive procedure and carries with it a small degree of unexpected risk (please
see Section C above).
I understand and agree that ENDOVISION PLUS INC considers all patients undergoing
colonoscopy and/or esophagogastroscopy to be eligible for transfer to an
acute care facility should its personnel deem it necessary.
Section E. CONSENT TO THE PROCEDURE AND TO THE TAKING OF SPECIMENS
DURING THE PROCEDURE
By signing this CONSENT AND INFORMATION FORM, I consent to this procedure
and to the removal during this procedure of any tissues or specimens that the
attending physician may think is required. I further consent that any tissues or
specimens removed from my body during the course of this procedure may be
tested and then disposed of as determined by the attending physician and/or
Endovision personnel. In addition, the physician has reviewed this procedure with
me. The risks of this procedure have been explained to me, that I have read or
had this form read and/or explained to me, that I fully understand its contents. I
have been given ample opportunity to ask questions. My questions have been
answered to my satisfaction, and I am also satisfied with the explanations that
have been provided to me regarding the procedure and its potential risks.
Billing: If you have a doctor’s referral and you are a Quebec resident the procedure
you are undergoing is covered by la Régie de l'Assurance Maladie du Québec
(RAMQ), and the doctor will bill RAMQ directly for the procedure. In addition Endovision
Plus Inc. charges a medication fee and a supplemental fee if you do not have your
doctor’s referral. If you are not a Quebec resident, each of these additional items is
individually billed on your invoice and is not covered by RAMQ. As a Result; I
understand that these additional services will be charged directly to me.
Please note that certain extended health-care insurance providers may cover a portion
of these services. You also may be able to declare them on your income tax, please
check with your insurance provider and or tax agent).
Patient signature _____________________ Date __________
Witness signature ____________________ Date ___________
Tel: 514-595-3636
Fax: 514-788-2313
www.endovisionclinic.com
SIGNATURE OF ATTENDING PHYSICIAN
I acknowledge that I have provided the patient with all reasonable and relevant
information, including the information regarding the procedure and potential attendant
risks that are outlined in this consent form.
I have answered all of the questions the Patient has put to me and have
obtained the Patient's informed consent for the colonoscopy and/or
esophagogastroscopy.
Physician signature _________________________ Date__________
FURTHER PATIENT WAIVER REGARDING THE USE OF ANY VEHICLE FOLLOWING THE
PROCEDURE
If you come with your own vehicle without an accompanying
responsible adult you will be required to sign below, acknowledging that you
have been informed that you are not allowed to drive your vehicle following the
procedure and receipt of medication.
Patient signature ____________________________Date and time____________
NB: PLEASE BRING THIS FORM COMPLETED AND SIGNED ON THE DAY OF YOUR
PROCEDURE.
.