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 *

Surveillance after previous sleeve gastrectomy or one-anastomosis gastric bypass surgery or have a mid-cal or minimizer ring implanted

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.

Sleeve Gastrectomy and One-Anastomosis (Mini) Gastric Bypass surgery both have the recognised potential of exposing the oesophagus to bile and/ or acid from reflux. Not everybody notices the reflux or will experience symptoms.

There are studies that have found patients after this surgery to have developed a condition known as Barrett's metaplasia of the oesophagus which is a change that occurs to the lining to make it more resistant to the chemical damage of bile and acid. Unfortunately, this change also increases the risk of transformation into a form of oesophageal cancer. This is the reason why you would have had a gastroscopy done prior to your surgery, to ensure you did not have this before, and now it requires ongoing surveillance.

The current recommendedations are for a gastroscopy to be performed 2-3 years after the initial surgery.

A decision will be made about ongoing surveillance based on the findings of this surveillance endoscopy.

Gastric calibration rings are foreign objects that have the risk of being able to erode or cause other side-effects. The Mid-cal ring manufacturer recommends surveillance on the device.

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.

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 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.

Consent for Dr Daniel Walker To Do Gastroscopy

YesNo

Dr Wong's colleague, Dr Daniel Walker who is also a bariatric surgeon, may be asked from time to time, to perform endoscopy on his behalf.

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.

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 (Gastroscopy) *

Consenting Doctor

Dr Jason Wong

General, Upper GI and Bariatric Surgeon

Operating out of North West Private Hospital and Mater Private Hospital

Consenting Doctor

Dr Aaron Lim

General, Upper GI and Bariatric Surgeon

Operating out of North West Private Hospital and Mater Redland Hospital

Dr Jason Wong (Sign at check-in)

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Dr Aaron Lim (Sign at check-in)

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