Metropolitan Liver Diseases

Colonoscopy is an examination of the colon with a fiber optic endoscope. This involves insertion of a flexible instrument into the rectum and then upward into the colon.

Colonoscopy may be only diagnostic, looking at the colon alone and/or possibly obtaining a biopsy of any abnormal tissue identified; or it may be therapeutic in which case a polyp may be removed or a bleeding site cauterized using an electrocautery device.

Your doctor will decide whether fluoroscopy will be necessary to assist in performing this examination. Fluoroscopy involves the use of x-ray equipment to examine the abdomen during insertion of the instrument.

PREPARATION: Either a liquid diet and laxatives for several days before the examination or a one day more vigorous preparation of liquids and Fleets Phospho-Soda taken the day before. Do not take any aspirin, aspirin-containing products or other similar drugs such as Advil or Motrin for one week prior to and subsequent to the procedure. Use Tylenol for headache.

HOSPITALIZATION: Ordinarily not required unless dictated by other medical circumstances.

SEDATION: Usually administered intravenously to insure that the patient is relaxed and comfortable. General anesthesia is not required.

RISKS: The risks of colonoscopy, including bleeding and perforation are relatively small and depend upon whether the examination is diagnostic or therapeutic. The risks are slightly greater in the elderly and in individuals with multiple previous abdominal operations, a history of abdominal infections or prior radiation therapy. Other risks include drug reaction from the medications used for sedation and possible vein irritation or pain at the site of the injected medicine.

Risks of Colonoscopy
Bleeding
Perforation

Diagnostic
Less than 1%
Less than 1%

Therapeutic
1.5-2%
Less than 1%

I have read the above information and understand the indications for and risks or this examination. I consent to the taking and reproduction of any photographs of the procedure for professional purposes. I hereby authorize and permit, M.D. and whomever he may designate as his assistants to perform upon me this procedure.

Furthermore, if any unforeseen conditions arise during this procedure requiring additional procedures, operations, or medications (including anesthesia or blood transfusions), I request and authorize the physician performing the procedure to do whatever he deems advisable in my best interests. If you have any questions after reading this form, please feel free to ask them before giving your consent.

Print Name:
Sign:	___________________
Date:
Witness:

PATIENT INFORMATION SHEET

Our office has been asked to schedule you for a screening colonoscopy.
Patients who have screening examinations have no signs or symptoms, and have a set benefit from their insurance company.

You need to be informed that if the physician performing your procedure finds a polyp or abnormality, your benefits may change and your insurance policy will pay
differently.

I acknowledge that I have read the above statement and will be responsible for my
deductible, co-pay and out-of-pocket expenses in the event that my scheduled screening examination does result in a procedure with a polyp or abnormality.

Patient Acount Number:

Procedure Date:

Patient Name:
Sign:	___________________
Date:
Witness: