The Endoscopy Center of Lake County, LLC



The Endoscopy Center of Lake County, LLC

CONSENT TO DIAGNOSTIC STUDIES/AND OR TREATMENT PROCEDURES

OHIO STATE LAW REQUIRES THAT WE OBTAIN YOUR CONSENT FOR YOUR MEDICAL PROCEDURES. YOU ARE BEING ASKED TO SIGN THIS FORM TO CONFIRM THAT THE PROCEDURE HAS BEEN DISCUSSED WITH YOU AND THAT YOU HAVE BEEN GIVEN SUFFICIENT INFORMATION UPON WHICH TO MAKE A DECISION, WHETHER TO HAVE THE MEDICAL PROCEDURE AND THAT CHOICE IS OF YOUR OWN FREE WILL.

I_________________________________, hereby authorize Dr. ______________________ with such associates or assistants as he/ she may select to diagnose and treat my condition. I understand the nature of the procedure necessary to diagnose and treat my condition to be:

________ESOPHAGOGASTRODUODENOSCOPY: Involves the passage of a flexible rubber tube. At the tip of it, there is a light and the other end is hooked to a TV monitor. It is inserted into the food pipe, down to the stomach and to the beginning of the small bowel. If needed, small tissue samples will be obtained. When indicated, the physician may also use instruments to stretch tight areas or cauterize specific sites.

________COLONOSCOPY: Involves the passage of a flexible rubber tube. At the tip, there is a light and the other end it hooked to a TV monitor. It is inserted into the anal and rectal region and advanced to the beginning of the large bowel. Biopsies may be taken or polyps may be removed.

________OTHER______________________________________________________________________

________I am participating in THE RESEARCH STUDY: _____________________________________

and have signed the appropriate consent forms.

The above listed procedure: the reasonably known risks relating thereto, including but not limited to: Perforation, hemorrhage, adverse reactions to the sedatives and the missing of significant neoplasms. Alternate methods of treatments have been explained to me by the above stated physician and all of my questions have been answered to my satisfaction. I acknowledge that no guarantee has been made to me as to the results of the medical procedure. I recognize and understand that during the course of the procedure, unforeseen conditions may necessitate additional or different procedures than those set forth previously herein. Because it is in my best interest, I therefore authorize, request and direct the above named physician, associates, assistants or other persons named by him, to perform such procedures as are in his professional opinion, necessary and desirable. I authorize the disposal of any tissue removed during the course of the above stated procedure. I also authorize and direct the above stated physician with associates or assistants to provide such additional services as they may deem reasonable and necessary. Including but not limited to the services of the Radiology Department and Laboratory. The authority granted herein shall extend to remedying conditions that are known to the above stated physician at the time the procedure is commenced.

Consent to the administration of such anesthetic(s) as may be considered necessary or advisable by the physician responsible for the service.

I understand in the event of a healthcare professional being exposed to my blood or body fluid, I am expected to have blood work, including an HIV and Hepatitis profile test drawn at a local lab.

I understand that my advance directives are suspended while I am a patient at the Endoscopy Center of Lake County, LLC.

This consent and acknowledgment of receipt of risk of information form is not to be construed or interpreted in any way by the undersigned patient, relative or representative as a promise, agreement, or representation as to or relating to, a medical prognosis. I hereby state that I have read and understand this consent.

It is my understanding that I may need to contact my insurance company to verify benefits and coverage for the above procedure.

___________________________________________ ____________________________________________

Signature of Patient/Guardian Date/Time

___________________________________________ 9-16

Signature of Witness

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