Gastroenterological Procedure Informed Consent Form

Patient Information

Name: _________________________ Date of Birth: _________________ Medical Record #: ______________

Procedure Details

Proposed Procedure(s): ___________________________________ Date of Procedure: ______________________________________

Consent Declaration

I, the undersigned, hereby authorize Dr. _________________ and associates to perform the following procedure(s):

• Upper Endoscopy (EGD)
• Colonoscopy
• ERCP
• Liver Biopsy
• Other: ___________________

Understanding of Procedure

I confirm that I have been informed of and understand:

1. The nature and purpose of the procedure
2. Expected benefits and potential risks
3. Alternative treatment options
4. Possible complications, including but not limited to:
   • Bleeding
   • Infection
   • Perforation
   • Adverse reaction to sedation
   • Missed lesions

Anesthesia Consent

I understand that:

• Sedation/anesthesia will be administered as deemed appropriate
• Additional risks associated with anesthesia have been explained
• I must arrange for transportation home after the procedure

Signatures

Patient/Guardian Signature: ___________________ Date: ________ Physician Signature: _________________________ Date: ________ Witness Signature: __________________________ Date: ________

Emergency Contact

Name: ______________________ Relationship: _______________ Phone: _____________________