Open Access Consent Form
Forms
Open Access Consent Form
FILL AND SUBMIT
You will be having a gastrointestinal procedure performed by Dr. Chahal. At the outset, you have indicated you do not need an office appointment for discussion of the procedure with Dr. Chahal. In the United States, colorectal cancer (CRC) is the second leading cause of cancer deaths (lung cancer is the leading cause). Approximately 150,000 new cases are diagnosed in the US every year and more than 55,000 Americans died from colorectal cancer in 2006. Screening has been shown to decrease mortality from CRC. Your primary care physician has referred you to have a screening colonoscopy.
The surgery center requires that you sign a permission slip in which you are certifying the Dr. Chahal has fully informed you about the procedure including such elements as the reason for the procedure, your expectations and responsibilities in preparing for the procedure, what is involved in the testing procedure, and risks to the procedure, which rarely, include serious or even life threatening complications.
Endoscopic procedures: Useful for both diagnostic (to find out if anything is wrong) and treatment purposes (remove polyps, look for bleeding sources and control bleeding, widen narrow passages, remove foreign objects…)
Colonoscopy: You will receive intravenous sedation for your comfort and a long lighted tube will be inserted into the rectum to the beginning of the colon to permit a complete exam. (Occasionally it is not possible to pass the scope safely through the entire colon and then a barium enema may be recommended) A polyp is a growth that is attached to the inside of the colon and is usually removed and sent for microscopic examination by a pathologist. Biopsy of the colon is often taken if the colonoscopy is being performed to investigate symptoms, in order to get as much information (microscopic) from the exam in addition to what is visualized by Dr. Chahal. It is imperative that the colon be entirely clean because small abnormalities may be missed if covered by stool. Possible complications: hemorrhage (bleeding) perforation (tearing) of the colon, or an adverse reaction/exaggerated response to the medications given.
Risks, Benefits and Alternatives: The risk of serious consequence from screening colonoscopy is very low. Potential serious complications include bowel perforation (approximately 1 in 1,000), heavy bleeding (approximately 1 in 500), and death (approximately 1 in 20,000). Other possible risks include adverse reaction to sedation, missed lesions, and potential for kidney impairment associated with certain bowel preparations (phospho-soda preps: Fleets & Osmo-Prep). Alternatives to a screening colonoscopy include a radiology test called a barium enema, a flexible sigmoidoscopy, yearly stool test cards which check for blood, and choosing not to have any investigation performed.
If you agree to proceed with your procedure(s) please print your name below, sign and date the form and return to our office by mail or fax. Please call the office to schedule an appointment or if you have any questions or concerns. Thank you.
PRINT AND FILL