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GARY M. ANNUNZIATA, D.O., F.A.C.P.
ANH T. DUONG, M.D.
JONATHAN C. LIN, M.D., MPH
INFORMED CONSENT FOR COLONOSCOPY

YOU HAVE BEEN SCHEDULED FOR A COLONOSCOPY FOR THE PURPOSE OF EXAMINING YOUR COLON
(LARGE INTESTINE) AND (IF APPLICABLE) REMOVING A POLYP OR POLYPS. THE COLONOSCOPIC
EXAMINATION IS DONE BY INSERTING A LONG FLEXIBLE TUBE INTO THE RECTUM AND BEYOND. IN MANY
CASES, THE INSTRUMENT CAN BE INSERTED THROUGH THE ENTIRE EXTENT OF THE LARGE INTESTINE,
PERMITTING A COMPLETE EXAMINATION. ABDOMINAL CRAMPS ARE USUALLY EXPERIENCED DURING THE
COURSE OF THE EXAMINATION. HOWEVER, YOU WILL BE SEDATED WITH MEDICATIONS, WHICH SHOULD
HELP WITH CRAMPING.

*** POSSIBLE COMPLICATIONS INVOLVED WITH THE COLONOSCOPY ***
A COLONOSCOPY IS GENERALLY A LOW RISK PROCEDURE. HOWEVER, ALL OF THE BELOW ARE POSSIBLE.
YOUR PHYSICIAN WILL DISCUSS THEIR FREQUENCY WITH YOU, IF YOU DESIRE, WITH PARTICULAR
REFERENCE TO YOUR OWN INDICATIONS FOR A COLONOSCOPY. YOU MUST ASK YOUR PHYSICIAN IF YOU
HAVE ANY UNANSWERED QUESTIONS ABOUT YOUR PROCEDURE.
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 AND/OR DRAIN THE AREA
IS USUALLY REQUIRED. RARELY IT CAN RESULT IN THE NEED FOR TEMPORARY OR PERMANENT
COLOSTOMY (A BAG TO RETAIN STOOL). A SURGERY WILL RESULT IN AT LEAST A WEEK IN THE
HOSPITAL WITH AN AVERAGE RECOVERY AT HOME FOR ABOUT A MONTH. PAIN AND LOSS OF
CONSORTIUM CAN BE EXPECTED.
BLEEDING- BLEEDING, IF IT OCCURS, IS USUALLY A COMPLICATION OF A BIOPSY, POLYPECTOMY, OR
DILATATION. MANAGEMENT OF THIS COMPLICATION MAY CONSIST OF CAREFUL OBSERVATION,
TRANSFUSION, REPEAT COLONOSCOPY OR A SURGICAL OPERATION.
MEDICATION PHLEBITIS- MEDICATIONS USED FOR SEDATION MAY IRRITATE THE VEIN IN NEAR THE
SITE OF INJECTION. PHLEBITIS CAUSES A RED, PAINFUL SWELLING OF THE VEIN AND SURROUNDING
TISSUE. THE AREA COULD BECOME INFECTED. DISCOMFORT IN THE AREA COULD PERSIST FOR
SEVERAL WEEKS TO SEVERAL MONTHS.
INFECTION- INFECTION MAY OCCUR AT THE INTRAVENOUS SITE. MANAGEMENT IS SPECIFIC TO
EACH SITUATION.
OTHER RISKS- INCLUDES DRUG REACTIONS AND COMPLICATIONS FROM OTHER DISEASES THAT YOU
MAY ALREADY HAVE. DEATH IS EXTREMELY RARE, BUT REMAINS A REMOTE POSSIBILITY. YOU
MUST INFORM YOUR PHYSICIAN OF ALL YOUR ALLERGIES AND MEDICAL PROBLEMS.
DIAGNOSTIC ERROR- A COLONOSCOPY IS THE MOST SENSITIVE AND ACCURATE METHOD TO
EVALUATE THE COLON. HOWEVER, IT IS POSSIBLE TO MISS A GROWTH OR CANCER IN THE WALL OF
THE COLON. THIS COULD OCCUR BECAUSE OF A POOR PREPARATION OR BECAUSE A GROWTH IS
BEHIND A FOLD. ANOTHER LIMITATION OF COLONOSCOPY IS THAT A SPECIFIC DIAGNOSIS OR
SOURCE FOR A PARTICULAR SIGN OR SYMPTOM MAY NOT BE FOUND, EVEN IF THE SOURCE IS IN THE
COLON. THE EXAM MAY BE NORMAL IN CERTAIN CASES. IF YOUR SYMPTOMS SHOULD CONTINUE,
FURTHER EVALUATION MAY BE NEEDED. IN THIS SITUATION IT IS YOUR RESPONSIBILITY TO NOTIFY
YOUR DOCTOR AND FOLLOW UP FOR FURTHER EVALUATION.
CONSCIOUS SEDATION- EVERY EFFORT IS MADE TO ENSURE A COMFORTABLE EXAM. CONTRARY TO
POPULAR BELIEF SOME PEOPLE REMEMBER THE EXAM. THIS IS NOT DUE TO IMPROPER SEDATION
PRACTICES. IT IS RELATED TO THE DOCTORS’ NEED TO KNOW WHEN YOU ARE EXPERIENCING PAIN.
IN ORDER TO MINIMIZE RISK. IN SOME PATIENTS, MORE SEDATION CANNOT BE GIVEN DUE TO A
LOW BLOOD PRESSURE, LOW OXYGEN LEVEL, CHANGE IN VITAL SIGNS OR OTHER FACTORS. IN
ADDITION, PATIENTS AT HIGHER RISK DUE TO MEDICAL PROBLEMS SUCH AS LUNG DISEASE,
SOMETIMES CANNOT BE SEDATED AT THE LEVEL OF NOT REMEMBERING. *** IF YOU ARE
SCHEDULED TO HAVE TWO PROCEDURES ON THE SAME DAY THERE IS A GREATER CHANCE OF WAKING
UP DURING THE SECOND PROCEDURE. ***
NOTICE TO ALL MALE PATIENTS- A COLONOSCOPY DOES NOT INCLUDE AN EXAM OF THE PROSTATE.
YOU SHOULD CONTACT YOUR PRIMARY CARE PHYSICIAN OR UROLOGIST FOR THIS EXAM, IT IS
GENERALLY RECOMMENDED YEARLY. ______________ (INITIAL HERE)
BLOOD THINNER CONSENT- I UNDERSTAND THAT BEING OFF OF BLOOD THINNING MEDICATION
INCREASES A RISK OF HAVING A STROKE, HEART ATTACK OR BLOOD CLOT. EVEN IF IT HAS BEEN
STOPPED IN THE PAST WITHOUT PROBLEMS, THE RISK STILL EXISTS. AFTER A POLYPECTOMY,
RESTARTING MY BLOOD THINNING MEDICATION DOES INCREASE THE RISK FOR BLEEDING. I
UNDERSTAND AND ACCEPT THIS RISK. _______________ (INITIAL HERE)
** PLEASE DISCONTINUE THE FOLLOWING MEDICATIONS ______ DAYS PRIOR TO YOUR PROCEDURE:
___ ADVIL
___ ALEVE
___ ANACIN
___ASCRITPIN ___ASPIRIN SUPP.
___ AGGRENOX
___ PERSANTINE

___ ASPIRIN
___BAYER ASPIRIN
___BUFFADYNE ___BUFFERINE ___COUMADIN

___DARVON COMOUND ___DIET DRUGS ___DRISTAN
___DURAGESIC ___ECOTRIN

___EMPIRIN
___EQUAGESIC ___EXCEDRIN
___FIORINAL
___GINGER
___GINGKO BILOBA

___INDOCIN
___IRON SUPPLEMENTS ___MIDOL
___MOTRIN
___NAPROSYN

___NAPROXEN ___NORGESIC
___PAMPRIN
___PEPTO-BISMOL
___PERCODAN

___PLAVIX
___ST. JOHNS’ WART
___TRIAMINICIN
___VITAMIN E ___ZOMAX

___OTHER-
___________________________________________________________________________________________________

10. ***ANTIBIOTIC USAGE PRIOR TO SURGICAL PROCEDURE***

DO YOU REQUIRE ANTIBIOTIC USAGE PRIOR TO ANY SURGICAL OR DENTAL
PROCEDURE?

______ YES

IF YOU INDICATE YES, WHAT IS THE REASON- ____________________________________.
WHAT MEDICATION IS PRESCRIBED?
___________________________________________________________________________________.
ALTERNATIVES TO A COLONOSCOPY

ALTHOUGH A COLONOSCOPY IS AN EXTREMELY SAFE AND EFFECTIVE MEANS OF EXAMING THE COLON, IT
IS NOT 100 % ACCURATE IN DIAGNOSIS. IN A SMALL PERCENTAGE OF CASES, A FAILURE OF DIAGNOSIS OR
MISDIAGNOSIS MAY RESULT IN OTHER DIAGNOSTIC OR THERAPEUTIC PROCEDURES, SUCH AS MEDICAL
TREATMENT, X-RAY, AND SURGERY. ANOTHER OPTION IS TO CHOOSE NO DIAGNOSTIC STUDIES AND/OR
TREATMENT. YOUR PHYSICIAN WILL BE HAPPY TO DISCUSS THESE OPTIONS WITH YOU.

BRIEF DESCRIPTION OF PROCEDURE (S)
COLONOSCOPY-
THIS IS AN EXAMINATION OF ALL OR PORTIONS OF THE COLON. OLDER PATIENTS
OR THOSE WITH EXTENSIVE DIVERTICULOSIS OR PREVIOUS PELVIC SURGERIES ARE
MORE PRONE TO COMPLICATIONS. A POLYPECTOMY (THE REMOVAL OF POLYPS) IS
PERFORMED IF NECESSARY BY THE USE OF A WIRE LOOP AND AN ELECTRICAL
CURRENT. COLON DECOMPRESSION MAY BE PERFORMED IF NEEDED.

GASTROINTESTINAL DILATATION-
IN SOME CASES DILATING TUBES OR BALLOONS ARE USED TO
STRETCH NARROW AREAS OF THE GASTROINTESTINAL
TRACT.
I CERTIFY THAT I UNDERSTAND THE INFORMATION REGARDING A COLONOSCOPY. I HAVE BEEN FULLY
INFORMED OF THE RISKS AND POSSIBLE COMPLICATIONS OF MY PROCEDURE. I HEREBY AUTHORIZE GARY M.
ANNUNZIATA D.O., F.A.C.P./ ANH T. DUONG, M.D./ JONATHAN LIN M.D AND WHOMEVER HE MAY DESIGNATE AS
HIS ASSISTANT (S) TO PERFORM UPON ME A:

COLONOSCOPY

IF FOR ANY UNFORESEEN CONDITION SHOULD ARISE DURING THIS PROCEDURE CALLING FOR, IN THE
PHYSICIAN’S JUDGEMENT, ADDITIONAL PROCEDURES, TREATMENTS OR OPERATIONS, I AUTHORIZE HE TO DO
WHATEVER HE DEEMS ADVISABLE. I AM AWARE THAT THE PRACTICE OF MEDICINE AND SURGERY IS NOT AN
EXACT SCIENCE. I ACKNOWLEDGE THAT NO GUARANTIES HAVE BEEN MADE TO ME CONCERNING THE RESULT
OF THIS PROCEDURE.

_____________________________
_______________________________
____________________
PATIENT NAME-PRINT
PATIENT SIGNATURE

_________________________________

AFTER THE PROCEDURE
FOLLOWING YOUR PROCEDURE, THE DOCTOR WILL SPEAK TO YOU ABOUT THE FINDINGS. DUE TO THE
SEDATION YOU MAY NOT REMEMBER THIS DISCUSSION. IF THERE IS NO BIOPSY TAKEN, YOU WILL BE
NOTIFIED BY MAIL OR YOU WILL RECEIVE A PHONE CALL FROM THE OFFICE REGARDING EXAM FINDINGS AND
TIME OF YOUR NEXT APPOINTMENT. IF YOU DO NOT RECEIVE NOTIFICATION FROM THE OFFICE, IT IS YOUR
RESPONSIBILITY TO CONTACT THE OFFICE.
IF THERE WERE BIOPSIES TAKEN DURING YOUR PROCEDURE, THE OFFICE STAFF WILL CONTACT YOU AT
LEAST 7-10 DAYS AFTER THE PROCEDURE WITH THE RESULTS. IF YOU DO NOT HEAR FROM US, DO NOT ASSUME
“NO NEWS IS GOOD NEWS” AND PLEASE CONTACT THE OFFICE.

__________________________________________________________
PATIENT SIGNATURE
BILLING REGARDING THIS PROCEDURE

THIS IS TO INFORM YOU THAT YOU HAVE THE POSSIBILITY OF RECEIVING THREE BILLS WHEN UNDERGOING
THIS PROCEDURE. THE BILLS WILL CONSIST OF THE PHYSICIAN BILL FOR PERFORMING THE PROCEDURE (FROM
OUR OFFICE), A BILL FROM THE FACILITY THAT THE PROCEDURE IS BEING PERFORMED AT (MIRAGE
ENDOSCOPY CENTER OR EISENHOWER MEDICAL CENTER), AND IF THERE ARE BIOPSIES RETRIEVED THEN YOU
WILL BE SUBJECT TO A BILL FROM PATHOLOGY.

____________________________________________________________
PATIENT SIGNATURE


I CERTIFY THAT I HAVE RECEIVED A COPY OF THIS ENTIRE CONSENT TODAY.
___________________________________________________
___________________________________
PATIENT SIGNATURE
____________________________________________ Most patients who undergo endoscopic procedures are generally comfortable and do not recall the procedure
with a standard sedation technique called conscious sedation (CS). This involves the use of a short acting
narcotic and a Valium-like medicine that creates sedation that is generally tolerable and safe. Conscious
sedation is the standard care for endoscopic procedure.

Although we make every attempt to ensure that you are comfortable during the procedure we cannot always predict
in advance of an endoscopic procedure who is going to experience pain, discomfort, or other reactions to the CS.
There is another type of sedation available called deep sedation (DS). Insurance companies traditionally do not pay
for this; however, it assures that there is generally no recollection of the procedure. Deep sedation is done under the
care of an anesthesiologist.
You have the option to request DS in advance of your procedure; however, this cannot be done during the procedure
in the event that you experience pain that is not responding to the traditional sedation method.
Therefore we are asking you to choose deep sedation or conscious sedation.

If you want DS, we will arrange to have your procedure done under anesthesia; cost estimates will be provided in this
circumstance. Please notify the scheduling office staff.
If you do choose to use a deep sedation technique during your procedure there may be an increased risk of
complications related to deep sedation and an increased risk of perforation of the gastrointestinal tract. By signing
below you are agreeing to this increased risk and that you have a copy of this document.
I am waiving my option to the deep sedation; I am requesting conscious sedation, signed:
_______________________/__________________/_______/_________ Print/Signature/Date/Time
I am requesting deep sedation as done by an anesthesiologist and accept the associated risk:
_______________________/__________________/_______/_________ Print/Signature/Date/Time
Desert Gastroenterology Consultants
Gary M. Annunziata, D.O., F.A.C.P.
Anh T. Duong, M.D.
Jonathan C. Lin, M.D., MPH
PREVENTATIVE OR SCREENING COLONOSCOPY EXAM –VS-
DIAGNOSTIC COLONOSCOPY EXAM
Please be advised that if you are being seen today for a preventative or screening
colonoscopy, it will not necessarily be billed as a preventative or screening
procedure. When the doctor performs the procedure, should there be polyps
found or the need for biopsies to be taken it will change the procedure from a
Preventative or Screening Colonoscopy (G0121 or G0105) to a Diagnostic
Colonoscopy (45378). If the doctor performs the procedure and there are no
biopsies or polyps removed, then it will be billed as a preventative or screening
procedure.

We advise that you please check with your insurance company to insure that you
have coverage for either of these procedures. We do obtain prior authorization for
the Colonoscopy, however, PRIOR AUTHORIZATION IS NOT A GUARANTEE
OF PAYMENT BY YOUR INSURANCE COMPANY.
By signing below, you are stating that you will contact your insurance company to
verify coverage for either procedure.
___________________________________
________________________
Patient Name- Please Print

____________________________________

Patient Signature

____________________________________

DESERT GASTROENTOROLOGY CONSULTANTS
A MEDICAL CORPORATION
PATIENT MEMORANDUM
TO: OUR PATIENTS
FROM: GARY ANNUNZIATA, D.O., F.A.C.P., ANH DUONG, M.D.,
JONATHAN C. LIN, M.D., MPH
SUBJECT: DISCLOSURES
FINANCIAL DISCLOSURE
Gary Annunziata, D.O., Anh Duong, M.D. and Jonathan C. Lin, M.D., MPH (collectively the “Physicians”) have ownership interest in DESERT GASTROENTEROLOGY CONSULTANTS, a Medical Corporation which owns and operates the clinical pathology laboratory located in the Physician’s office. The Physicians generally refer their clinical pathology laboratory work to the on-site clinical pathology laboratory operated by DESERT GASTROENTOROLOGY CONSULTANTS, a Medical Corporation. You have the right to choose another clinical pathology laboratory for the purpose of having any of your pathology work or assignment performed. If you desire to choose another clinical pathology laboratory to have pathology work or assignment performed please let the office manager or your Physician know. ________________________________________ Dated:__________________ Patient Name- Please Print ________________________________________ Patient Signature

Source: http://www.desertgastro.net/client_files/file/Colonoscopy_Consents-Form.pdf