ASC Procedure Instructions & Forms

Colonoscopy Forms - Authorization and Informed Consent

Patient Name:
GI Endoscopy Procedures (✔ Check the procedure that applies to you)

Monitored Anesthesia Care with Deep Sedation

Administration of Anesthesia: You will receive the administration of several medications via an IV to provide reduced level of consciousness, and will be administered by a licensed anesthesiologist or Certified Registered Nurse Anesthetist (CRNA).

Primary Risks and Complications

GI endoscopy is generally a low risk procedure. However, complications are possible no matter how careful one is. Your physician will discuss their frequency with you, if you desire, with particular reference to your own procedure.

Perforation: The procedure may result in an injury to the gastrointestinal tract wall with possible leakage of gastrointestinal contents into the body cavity. If this occurs, hospital admission and surgery may be required.

Bleeding: Bleeding may occur. Management may consist only of careful observation but may require transfusions, endoscopic cautery or possible surgery.

Risks of Sedation: For your safety, your heart rhythm, pulse, blood pressure and oxygen saturation will be monitored. Possible complications of sedation include, but are not limited to, respiratory depression and disturbances of the heart rhythm.

Medication Phlebitis: Medications used for sedation may occasionally irritate the vein in which they are injected. This causes a red, painful swelling of the vein and surrounding tissues, which may persist for several weeks.

Other Risks: Include but are not limited to drug reactions and complications from other diseases you may already have. Instrument failure and death are extremely rare, but remain remote possibilities.

I certify that I understand the information regarding these procedures and that I have been fully informed of the risks, possible complications thereof and alternatives to the procedure, including "to do nothing". I consent to the taking of biopsies and reproduction of any photographs taken in the course of this procedure for professional purposes. I am aware that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantees have been made to me concerning the results of the procedure. I authorize , MD to proceed with the scheduled procedure.
I understand that I am responsible for all financial obligations incurred for this procedure and I will fulfill my obligations in a timely manner. In the event that I do not meet my financial obligations, all attempts may be made to collect the outstanding balance, up to and including use of collection services. I will be responsible for any fees associated with collection of unpaid balances.
I hereby acknowledge receipt of the "Information about Your Outpatient Visit" brochure.


Patient's Signature (or Legal Guardian): name in field below will act as signature