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ALISTER A. GEORGE, M.D.
509 Marin Street, Suite 134, Thousand Oaks, CA 91360 INFORMED CONSENT FOR COLONOSCOPY
After careful medical evaluation and assessment your physician has recommended that a colonoscopy be performed. Colonoscopy is a safe procedure allowing direct visualization of the inside of the large intestine (colon) with a colonoscope. This is a flexible tube with a light and camera on the end, which is passed through the rectum into the large intestine. The physician will examine the lining of your colon and may take biopsy specimens (tiny bits of tissue) or remove polyps, (a small growth that can become a cancer). This is done using a wire snare and cautery through the colonoscope. You will not feel any sensation or discomfort if a biopsy or a polyp is removed. You will be given sedation to help you relax during the examination. You will be asleep during the examination but may feel mild abdominal cramps or discomfort briefly when water or air is used through the colonoscope. Please note that all endoscopic procedures have potential risks and complications and colonoscopy is no exception. The risks and potential complications of this examination which have been explained to you are an accepted part of the procedure. The medication used for sedation can infrequently cause an allergic reaction. When this occurs it is usually mild, commonly in the form of rashes or hives, or itching at the sight of the IV catheter in your hand. More serious reactions such as loss of blood pressure and shock are uncommon and are usually successfully treated. Significant bleeding can occur but is uncommon. Serious infections of the abdomen or heart valves are quite uncommon. Perforation (puncture) of the wall of the colon is also very rare, but it can occur. If these occur, they are usually treated, if possible, without surgery. However surgery may be needed to repair the puncture or for possible colostomy and prolonged hospitalization may be necessary in some instances. Even death can occur but is extremely rare. The alternative to this procedure is a barium enema (infusing barium into the colon via the rectum and taking x-ray pictures). Please inform your physician if you have had any of the following: ALLERGIC REACTIONS TO MEDICATIONS; ARTIFICIAL HEART VALVES; PREVIOUS ENDOCARDITIS; PREVIOUS RADIATION THERAPY; HEAR, LUNG, OR KIDNEY PROBLEMS. CURRENT USE OF MEDICATIONS SUCH AS COUMADIN (warfarin), ASPIRIN, MOTRIN, ADVIL, NAPROSYN, ALEVE, OR NARDIL (phenelzine), ELDEPRYL (somerset), PARNATE, etc. The discussion with your physician and the above description is designed to inform you of what a colonoscopy entails including the risks and benefits, complications and alternatives. If you have particular questions, please be sure to discuss them with your physician. Your signature below constitutes your acknowledgement (i) that you have read and agree to have a colonoscopy with possible polypectomy, biopsy and dilatation, (ii) that this procedure has been adequately explained to you by your attending physician and that you have all of the information that you desire, and (iii) that you authorize and give informed consent to the performing of this procedure. I, _____________________________________, Hereby authorize the above mentioned procedure to be performed by Dr. Alister A. George. X ____________________________________________________ Signature of patient X ____________________________________________________

Source: http://www.mygastrodoc.com/colonconsent.pdf