Informed Consent for Manometry Houston Sleeve Surgeon

Patient's Full Name*

First NameLast Name

Authorized Representative (Optional)

First NameLast Name

Relationship of Representative (optional)

INFOMED CONSENT for Manometry.

It is very important for Houston Heartburn and Reflux center, and Dr. Elias Darido that you understand and consent to the treatment your doctor is rendering and any procedure your doctor may perform. You should be involved in all decisions concerning surgical procedures your doctor has recommended. Sign this form only after you understand the procedure, the anticipated benefits, the risks, the alternatives, the risk associated with the alternatives and after all your questions have been answered. Please initial and date directly below this paragraph indicating your understanding of this paragraph.

Patient’s Initials or Authorized Representative*

Date

Explanation of Procedure:

Esophageal manometry catheter placement consists of inserting a soft pressure sensor catheter through the nose into the esophagus to measure esophagus contractions and lower esophagus sphincter pressure. The procedure is a low-risk procedure. However, complications can occur and are not limited to perforation or bleeding.

Passage of the esophageal manometry catheter may result in injury to the upper airway, pharynx, esophagus or stomach wall resulting in bleeding or perforation. Leakage of saliva or gastrointestinal contents may occur. Surgery to close the leak and or drain the region may be required to fix the problem.

I, {patientsFull}, hereby authorize Dr. Darido and any associate or associates the doctor deems appropriate, to insert esophageal manometry catheter.

I have been fully informed of the risks and possible complications of my procedure and have been given the opportunity to ask questions. I understand that unforeseen conditions may be revealed that may necessitate change or extension of the original procedure or a different procedure than those already explained to me. I therefore authorize and request that the above-named physician, his assistants or designees may perform such procedures as necessary and desirable in the exercise of his/her professional judgment.

Patient's Full Name*

First NameLast Name

Signature of Patient or Authorized Representative*

Date

The Patient/Authorized Representative has read this form, or had it read to him/her.The Patient/Authorized Representative states that he/she understands this informationThe Patient/Authorized Representative has no further questions

CERTIFICATION OF PHYSICIAN: I hereby certify that I have discussed with the individual granting consent, the facts, anticipated benefits, material risks, alternative therapies and the risks associated with the alternatives of the procedure(s).

Doctor Signature

Date

USE OF INTERPRETER OR SPECIAL ASSISTANCE

An interpreter or special assistance was used to assist patient in completing this form as follows:

☐ Foreign language (specify)

☐ Sign language

☐ Patient is blind, form read to patient

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Interpretation provided by

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Name of Interpreter and Title or Relationship to Patient

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Signature (Individual Providing Assistance)

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