Gastroscopy Consent

Full Name *

Date of Birth *

Email address *

Current Weight *

Medication History *

Current Medications including blood thinners and GLP-1 analogues *

How often do you smoke? *

Allergies *

Are you currently pregnant or breastfeeding? *

Purpose for Gastroscopy *

For evaluation and diagnosis of upper abdominal symptoms or suspected pathology

The oesophagus, stomach and first part of the small intestine called the duodenum are inspected with a gastroscopy. Therefore any abnormalities occuring on the inside of these organs on their lining can potentially be identified, biopsied and sometimes removed using a flexible camera known as an endoscope.

It is the recognised investigation for a variety of conditions and symptoms such as gastroesophageal reflux, hiatus hernia, swallowing problems, iron deficiency anaemia, weight-loss, bloating, upper abdominal discomfort or pain, food intolerances and more.

Other

How is the gastroscopy performed?

The procedure is done as a day procedure usually under a sedation administered by the anaesthetist, where you will not be awake or aware of any of the procedure.

Sometimes a numbing agent is sprayed in your throat also.

The procedure only takes a few minutes. You will be asked to lay on your side and a bite-block placed between your teeth to stop you from biting on the gastroscopy.

The gastroscope is a flexible tube about as wide as your little finger, that is passed down your throat through your mouth, to inspect the food pipe (your oesophagus), the stomach and first part of the small intestine. Some biopsies may be taken.

Occasionally interventions are required to be performed at the time of gastroscopy subject to endoscopic findings

Click HERE to watch an animation about how a gastroscopy is performed

Risks of a gastroscopy

The procedure is very safe.

Occasionally damage can occur to teeth, lips, gums from the scope or mouth piece to protect the scope.

Missed pathology, causing bleeding or perforation are all rare and unlikely risks.

Discomfort, bloating, sore throat are all possible side effects from the procedure.

Sometimes a second procedure may be required.

Aspiration pneumonia is uncommon.

Blood Products Administration

Not required / Not applicable

Clinical Photography and Video

It is standard practice for Dr Wong or Dr Lim to capture images whilst performing the gastroscopy procedure and it form part of the medical report for your surgery stored with the hospital and Brisbane General & Obesity Surgery.

Gastroscopy Consent Confirmation *

I have a good understanding of the procedure that has been offered to me.I have a good understanding and acceptance of the risks of having procedure.I understand a non-complex intervention may be performed (such as removing a polyp or dilating a stricture) if it is deemed clinically necessary and beneficial, based on endoscopic findings at the time of the procedure

Patient Consent

I am covered for the proposed surgery by a private health insurance fund

YesNo

Patient Declaration

I am aware the Fee Estimate related to the proposed treatment may change as a result of variations in the actual treatment provided based on clinical judgement at time of surgery.I have been advised that other health professionals may be involved in my treatment and I understand that this estimate does not include their fees or charges unless specifically stated otherwise.I am aware I may receive separate accounts from other service providers associated with my treatment, including from my surgeon, surgical assistant, anaesthetist, hospital, pharmacy, allied health and other physicians who may be involved in my care.I understand that as a private patient I am responsible for all hospital, diagnostic and prosthetic costs that are not covered by my health fund or Medicare. - this can include but is not restricted to pathology, blood tests and medical imaging.The patient or nominee named herein undertake to pay the patient payment as indicated, together with any unforeseen costs which may arise as a consequence of the procedure(s).I agree for eligible follow-up appointments to be "bulk-billed" to Medicare and the benefit to be assigned to Dr Wong or Dr Lim.I understand the Financial Information and Fee Estimate that I have been issued, and accept to pay all costs related to my operation as disclosed above and in those documents. I understand that the quoted Fee Estimate is valid for 6 months.

Patient Name

Patient Signature (Gastroscopy) *

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Date of Consent *

Consenting Doctor

Dr Jason Wong

General, Upper GI and Bariatric Surgeon

Operating out of North West Private Hospital and Mater Private Hospital

Dr Aaron Lim

General, Upper GI and Bariatric Surgeon

Operating out of North West Private Hospital, Mater Redland Hospital, Moreton Day Hospital

Dr Jason Wong - Signature

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Dr Aaron Lim - Signature

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