Procurement & Policies

Patient Name

Date of Birth

I consent to have the following diagnostic examination performed by Dr. Goldstein, Dr. Prosky, or Dr. Vemana.

Upper Endoscopy (EGD)- Examination of the esophagus (food pipe), stomach, and duodenum (first portion of the small intestine)

with biopsy

with dilation of the esophagus

Colonoscopy-Examination of the Colon

with biopsy

with polypectomy (removal of small growths using a wire loop or an electrical current)

Other

Please read the following statements:
I understand that there may be risks associated with any endoscopic examination. Potential complications may include risk of drug reaction, localized swelling of the arm following intravenous medication, or bleeding. Serious complications such as bleeding or perforation of the intestinal wall can occur but are usually associated with polypectomy or dilation. Excessive bleeding may require blood transfusions and perforation may require surgical intervention.

I understand that these procedures are not always accurate and that diagnostic errors can occur.
If any unforeseen condition arises during this procedure, I authorize Dr. Goldstein, Dr. Prosky, or Dr. Vemana to do whatever is deemed medically necessary.
Please note that there is a professional fee, a facility fee, an anesthesia fee, and possibly a pathology fee associated with this procedure. You will receive separate bills for each fee. If you have questions about your out of pocket expense you should contact your insurance carrier.

Procedure Cancellation/Rescheduling Policy: (Please initial to acknowledge the statements below.)

Northern Virginia Gastrointestinal Associates, a division of Advanced Digestive Care, requires 7 business days' notice prior to canceling or rescheduling your procedure. There will be a $350 fee assessed for failing to appear for your scheduled procedure or for not providing 7 business days notice to cancel/reschedule.

Transportation Policy: (Please initial to acknowledge the statements below.)

You MUST make arrangements for an adult (18+) to drive you home.
YOU MAY NOT TAKE A TAXI, UBER, or LYFT unless accompanied by an adult (18+). The facility you are scheduled with has reserved the right to confirm your transportation prior to your procedure
If you do not have a confirmed ride, your procedure will be cancelled.
If your procedure is scheduled at Woodburn Endoscopy Center for 2:00 PM or later, YOUR RIDE MUST REPORT TO THE CENTER DURING YOUR CHECK-IN PROCESS AND REMAIN AT THE FACILITY.
If your procedure is scheduled at McLean Surgical Center, your ride MUST REMAIN AT THE SURGICAL CENTER DURING YOUR PROCEDURE. THIS POLICY IS ENFORCED BY THE FACILITY AS WELL.
You should NOT operate any heavy machinery for at least 12 hours after receiving medication for sedation.

Initials

**PLEASE NOTIFY OUR OFFICE IF YOUR INSURANCE PLAN CHANGES BEFORE THE DATE OF YOUR PROCEDURE**

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature

Date

Advanced Digestive Care Representative

Date

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