Interventional Gastroscopy Consent

Full Name *

Date of Birth *

Email address *

PROCEDURE NAME:

PROCEDURE DETAILS:

Purpose for Gastroscopy *

For evaluation, diagnosis and treatment of upper gastrointestinal problems

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. Other problems such as obstruction, narrowings, leak defects, infection, bleeding and other problems can be treated using the endoscope. This is done using devices that pass down the endoscopy such as a stent, drain, cautery, clips, basket and other equipment.

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. In some situations when doing more complicated interventional procedures, a full general anaesthetic may be used to protect your airway from aspiration.

Sometimes a numbing agent is sprayed in your throat also.

The procedure will usuall take a few minutes to half an hour or longer, depending on the complexity of the intervention. 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.

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.

Sometimes multiple interventions may be required to be effective or it may not be possible to perform the intended intervention.

Blood Products Administration

This is extremely unlikely to be required for this procedure

Clinical Photography and Video

It is standard practice for Dr Wong to capture images whilst performing the gastroscopy procedure and it form part of the medical report for your surgery stored with the hospital and Dr Wong's practice.

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.

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 am satisfied with the explanation of the procedure and have been given ample opportunity to ask questions.I understand that I will have further opportunity for questions prior to the procedure where the consent will be confirmed again,

Patient Name

Patient Signature (Gastroscopy) *

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Date of Patient Signing Consent *

Consenting Doctor to reconfirm consent and sign on day of procedure

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 and Mater Private Hospital

Dr Jason Wong Signature

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Dr Aaron Lim Signature

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