Informed Consent for Endoscopy

INFOMED CONSENT for endoscopy.

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.

Explanation of Procedure:

Esophagogastroduodenoscopy, EGD, with possible biopsy and polypectomy, possible
balloon dilation Direct visualization of the digestive tract with lighted instruments is referred to as gastrointestinal endoscopy. Your physician has advised you to have this type of examination. The following information is presented to help you understand the reasons for and the possible risks of this procedure. At the time of your examination, the lining of the digestive tract will be inspected thoroughly and possibly
photographed. If an abnormality is seen or suspected, a small portion of tissue (biopsy) may be taken, or the lining may be brushed. These samples are sent to a pathology laboratory to determine if abnormal cells are present. Small growths (polyps), if seen, may be removed. To keep you comfortable during the procedure, an
anesthesiologist will administer medication in the vein.

Brief Description of Endoscopic Procedures

1. EGD (Esophagogastroduodenoscopy): Examination of the Esophagus, stomach, and duodenum.
2. Esophageal Dilation: Dilating tubes or balloons are used to stretch narrow areas of the esophagus.

Principle Risk and Complications of Gastrointestinal Endoscopy

Gastrointestinal endoscopy is generally a low-risk procedure. However, all the following complications are possible
and are not limited to:

1. Perforation: Passage of the instrument may result in an injury to the gastrointestinal tract wall with possible leakage of gastrointestinal contents into the body cavity. If this occurs, surgery to close the leak is usually required.
2. Bleeding: bleeding, if it occurs, is usually a complication of biopsy, polypectomy or dilation. Management of this complication may consist only of careful observation, or may require transfusions, repeat endoscopy to stop the bleeding or possibly a surgical operation
3. Medication Phlebitis: Medications used for sedation may irritate the vein in which they are injected. This causes a red, painful swelling of the vein and surrounding tissue. The area could become infected. discomfort in the area may persist for several weeks to several months.
4. Other Risks: Include drug reactions, complications from other diseases you may
   already have, and not being able to complete the exam. Instrument failure and death are extremely rare but remain remote possibilities.

YOU MUST ASK YOUR PHYSICIAN IF YOU HAVE ANY UNANSERWED QUESTIONS ABOUT YOUR TEST.

YOU MUST INFORM YOUR PHYSICIAN OF ALL YOUR ALLERGIC TENDENCIES AND MEDICAL PROBLEMS.

Alternatives to Gastrointestinal Endoscopy

Although gastrointestinal endoscopy is an extremely safe and effective means of examining the gastrointestinal tract, it is not 100 percent accurate in diagnosis. In a small percentage case, a failure of diagnosis or misdiagnosis may result. Other diagnostic or therapeutic procedures, such as medical treatment, x ray and surgery are available.
Another option is to choose no diagnosis studies and/or treatment. Your physician will be happy to discuss these options with you.
Physician explained procedure: Dr. Elias Darido

I also authorize the administration of anesthesia for my comfort, and safety. I understand that because of sedation I may not drive or operate machinery make critical decisions, sign legal documents or consume alcoholic beverages the day of the procedure. I have been fully informed of the risks and possible complications of my procedures/anesthesia and have been given the opportunity to ask questions. I understand that unforeseen conditions may be revealed a n d may necessitate change or extension of the original procedure(s) or a different procedure(s) 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. I understand the Endoscopy Center does not recognize Do Not Resuscitate orders and will use all measures possible to sustain life. I am aware that the practice of medicine and surgery is not an exact science. I acknowledge that no guarantees have been made to me concerning the result of this procedure.

1. As a courtesy to our patients, insurance claims will be submitted on the patient's behalf to the insurance company(s) specified during the registration process; provided we have the complete name and address of the insurance
   company, and the subscriber's name, social security number and birth date.
2. All co-payments are due and collected at the time of service as required by the contract between the patient, the insurance company and our center.
3. Some insurance plans require pre-certification, pre-authorization or a written referral. It is the patient's responsibility to understand their insurance plan requirements and ensure that the proper authorization is obtained at least 3 days prior to the date of service. Failure to do so may result in denial of the claim by the insurance company. We cannot accept responsibilities for a disputed claim. If your insurance company denies the claim for any reason or withholds payment, you are ultimately responsible for the balance.
4. We recognize that there may be times when full payment is not possible. Patients without insurance are expected to pay a minimum of 50% of the cost at the time of service and a minimum of one third of the remaining balance over
   each of the three months following the date of service.
5. If you are having financial difficulty or have questions, please contact our billing office at 832.945.8717 or send email to biller@houstonheartburn.com, to discuss your account. Payments are expected to be paid prior to the time of service. Non-payment of accounts after three months may result in referral to an outside collection agency that could impact the patient's credit record.

I have read the above and understand and agree to the terms set forth in this Acknowledgement of Financial Responsibility and that regardless of any insurance coverage I may have, I am ultimately responsible for payment of my account with Houston Heartburn & Reflux Center and Hospital.