SGI Pediatric New Patient Paperwork

Southeastern Gastroenterology Pediatrics New Patient Paperwork
Welcome to Southeastern Gastroenterology Associates!
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Southeastern Gastroenterology New Patient Consent to Routine Procedures and Treatments
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Initial any Procedure and/or section of this form for which consent is granted.

	Intials
Needle sticks such as shots, injections, or intravenous lines to administer fluids or medications. Material risks include, but are notlimited to infection, infiltration (fluid from an IV leaking into tissue), disfiguring scar, nerve damage with possible loss of limbfunction. Alternatives to needle sticks (if available) include oral, rectal, nasal, or topical medications (each of which may be lesseffective) or refusal of treatment.
Physical tests, assessments and treatments such as internal body examinations, wound cleaning and wound dressing. Material risksinclude allergic reaction and infection. Apart from using modified procedure and/or refusal of treatment, no practical alternativeexists
Drawing blood or bodily fluids with a needle or taking tissue samples (biopsy). Material risks include but are not limited to infection, damage to joint or organ, nerve damage, and bleeding
Administration of medication whether orally, rectally, topically, or through the eye, ear, or nose. Material risks include, but are not limited to, allergic reaction, puncture, and perforation. Apart from varying the method of administration and/or refusal of treatment, no practical alternative exists
Insertion of internal tubes such as scopes, catheters, drainage tubes, etc. Material risks include but are not limited to internal injuries, bleeding, infection, and difficulty urinating after long term catheter placement. Apart from external collection devices or refusal of treatment, no practical alternative exists

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Southeastern Gastroenterology New Patient Financial Policy
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Southeastern Gastroenterology New Patient HIPAA Acknowledgement
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Southeastern Gastroenterology New Patient Records Release
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Patient Name
Patient's Date of Birth

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Last 4 digits of patient's social security number
Information NOT to be disclosed
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Southeastern Gastroenterology Office Visit Cancellation Policy
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