IMPORTANT NOTICE
Certain medical conditions require antibiotics before and after undergoing endoscopic procedures such as: colonoscopy, sigmoidoscopy, upper GI endoscopy and esophageal dilation.

Please notify our office if you have any of the following conditions:
• Rheumatic Heart Disease
• Valvular Heart Disease
• Heart Valve Replacement
• Vascular Surgery with graft replacement (aneurysm repair)
PLEASE INDICATE ANY DRUG ALLERGIES, SPECIFICALLY TO ANTIBIOTICS
Please provide us with this information at least several days before your scheduled procedure, so that we may prescribe appropriate antibiotics before you have your procedure.

PREPARATION
NOTHING TO EAT, DRINK, CHEW OR SMOKE after midnight the night before the examination. You may, however, take you regular medications with a sip of water.

DO NOT take 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 headaches or other discomforts.

Arrange to have someone pick you up after the procedure. A taxi may be used only if a responsible adult accompanies you. Because you are given a sedative DO NOT drive your car for 12 hours after the procedure.

Consent Form

I have read the above information and understand the indications for, and risks of 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. If you have any questions after reading this form, please feel free to ask them before giving your consent.

Print Name:
Sign:	___________________
Date:
Witness:

Post Procedure
Please arrange to have someone pick you up after the liver biopsy. The hospital will not permit you to use public transportation. A taxi may be used only if a responsible adult accompanies you. DO NOT drive a car for 12 hours after the liver biopsy